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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 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 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 334 552 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 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 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 335 552 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 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 336 552 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 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 337 552 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 HR FX 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 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 338 552 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 339 552 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 340 552 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 06 000 00000 XXXXX 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 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 341 552 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 342 552 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 00000000000000 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 343 552 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 XX 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 344 552 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 345 552 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 XXX 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 346 552 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 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 347 552 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 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 348 552 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 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 349 552 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 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 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 350 552 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 351 552 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 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 352 552 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 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 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 353 552 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 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 354 552 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 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 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 355 552 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 356 552 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 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 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 357 552 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 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 358 552 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 DCP XXXX 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 359 552 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 00 B DH 000000000000000 XXX XXX 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 360 552 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 361 552 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 C XXX XXX 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 362 552 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 XXX 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 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_11 |
- Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 361 552 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 C XXX XXX 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 362 552 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 XXX 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 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 363 552 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 364 552 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 ST 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 365 552 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 366 552 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 367 552 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 E1 Y L3 XX 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 368 552 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 369 552 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 XXX BO XXX 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 370 552 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 X BG X BG XXX BG X BG XXX BG XXXXX BG X B G X BG XXXXXX BG XXX BG XX BG XX 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 Usage notes 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 371 552 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 372 552 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 373 552 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 374 552 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 375 552 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 XXX ABF XXXXXX ABF X ABF XX BF XXXX BF XX X BF XXX BF X ABF XX BF XX ABF XXXX ABF XX 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, 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 376 552 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-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 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 377 552 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-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 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 378 552 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-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 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 379 552 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-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 380 552 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 381 552 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 382 552 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 02 00 000000000 XX 0000000 X 00000000 T 1 3 4 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 383 552 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 384 552 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 385 552 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 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 XXXX XXXXX 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 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 386 552 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 387 552 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 0B 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 388 552 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 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 The Rendering Provider must be a member of the Billing Provider Group in the Texas Medicaid system. The Rendering Provider is the same as the Performing Provider. Example NM1 82 1 XXXXXX XXXX XX XXXX XX XXX If | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_12 |
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 387 552 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 0B 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 388 552 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 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 The Rendering Provider must be a member of the Billing Provider Group in the Texas Medicaid system. The Rendering Provider is the same as the Performing Provider. Example NM1 82 1 XXXXXX XXXX XX XXXX XX XXX 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 Usage notes If the rendering provider loop is sent the rendering provider name is mandatory for Texas Medicaid claims processing 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 389 552 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 Usage notes NPI must be submitted unless the provider has an API assigned which will be reported in Loop 2310B Rendering Provider Secondary Identification. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 390 552 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 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 Usage notes If sent, the Rendering Provider Taxonomy Code must match 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 391 552 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 G2 XXX Max use 4 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. 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 392 552 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 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 X 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 393 552 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 394 552 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 XXXXX 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 395 552 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 XXXXXXX 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 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 396 552 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 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, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 397 552 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 XXXXXX TE XXXXXX EX XX 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 398 552 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 399 552 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 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 XXXX X XXXX XXXXX 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 400 552 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 401 552 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 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 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 402 552 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 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 403 552 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 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 404 552 2310E Ambulance Pick-up Location Loop end 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 XXXX XX XXXXX 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 405 552 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 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 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 406 552 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 XXX 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 407 552 2310F Ambulance Drop-off Location Loop end 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 XXXXX XX XXXXXXXX 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 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 408 552 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 U 21 XXXX XXXXX 13 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 409 552 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 410 552 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 411 552 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 OA X 000000000000 0 XX 000000000000000 000000 0000000 X 0000000000 000000 XXXXX 00000 00 XXXX 0 00000 00000 XXXXX 000000000000000 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 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 412 552 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 413 552 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 414 552 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 0000000000000 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 415 552 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 00000 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 416 552 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 00 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 417 552 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 Y 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 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 418 552 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 0 00000000000 X XXXXX XXX X XXXX 000000000000 00 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 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 419 552 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 420 552 2330A | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_13 |
25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 418 552 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 0 00000000000 X XXXXX XXX X XXXX 000000000000 00 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 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 419 552 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 420 552 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 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 XXXX XXXXXX XX X MI 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 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 421 552 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 422 552 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 XXXXXX 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 423 552 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 XXXXX 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 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 424 552 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 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 425 552 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 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 XXXXXX PI 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 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 426 552 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 427 552 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 XXX 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 428 552 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 XXX 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 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 429 552 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 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 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 430 552 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 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, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 431 552 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 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 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 432 552 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 XXX 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 433 552 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 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 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 434 552 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 NF 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 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 435 552 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 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 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 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 436 552 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 1G 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, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 437 552 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 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 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 438 552 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 0B 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 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 439 552 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 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 440 552 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 XX 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 441 552 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 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 442 552 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 G2 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 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 443 552 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 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 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 444 552 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 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 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, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 445 552 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 Texas Medicaid will accept up to 28 Service Lines per claim. 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, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 446 552 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 IV XXXXX XX XX XX XX X 0 MJ 0 XX 00 0 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; 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 447 552 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 Usage notes Texas Medicaid is requesting data sent in this field be UN for proper adjudication of the file. MJ Minutes 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 448 552 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 Texas Medicaid can accept a maximum of 99,999.99 for the units counted for claims processing. 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 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 449 552 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. 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 450 552 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 XX DA 000000 000000 00000000000 4 Max use 1 Optional SV5-01 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Max | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_14 |
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 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 449 552 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. 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 450 552 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 XX DA 000000 000000 00000000000 4 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 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 451 552 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 452 552 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 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, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 453 552 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 MT FT AC XXXXX 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 454 552 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 455 552 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 456 552 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 000000000 A DH 00000000000 X XXX 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 457 552 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 458 552 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 I MO 0000 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 459 552 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 Y 01 XXX XX XXX XXX 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 460 552 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 461 552 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 38 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 462 552 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 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 463 552 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 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 464 552 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 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 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 465 552 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 XXXX 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 466 552 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 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, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 467 552 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 468 552 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 469 552 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 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 - 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 470 552 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 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. 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 471 552 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 472 552 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 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 - 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 473 552 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 000000000000000 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 474 552 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 475 552 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 TR R4 00 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 476 552 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 02 000000000 0000 XXXX 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 477 552 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 478 552 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 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 479 552 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 XX 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 480 552 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 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 481 552 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 | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_15 |
view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 479 552 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 XX 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 480 552 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 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 481 552 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 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 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 Usage notes Texas Medicaid is requesting data sent in this field be 6R for proper adjudication of the file. 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 482 552 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 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 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 483 552 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 XXXXX 2U 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 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 484 552 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 485 552 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 XX 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 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 486 552 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 487 552 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 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 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 488 552 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 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 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 489 552 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 0000000000 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 490 552 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 000000000 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 491 552 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 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, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 492 552 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 XXXXXX 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 493 552 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 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 494 552 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 000 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 495 552 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 04 000000000000000 00 XXXXX 000000000 XXXXX X 00000000000 HC XXXXXX MJ 000000000 T2 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 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 496 552 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 497 552 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 498 552 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 499 552 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 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 500 552 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 0000 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, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 501 552 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 XZ XXXXX 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 502 552 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 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 The Rendering Provider must be a member of the Billing Provider Group in the Texas Medicaid system. The Rendering Provider is the same as the Performing Provider. Example NM1 82 2 XXXXXX XXXX XX XX 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 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 Usage notes If the rendering provider loop is sent the rendering provider name is mandatory 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 503 552 for Texas Medicaid claims processing 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 Usage notes NPI must be submitted unless the provider has an API assigned which will be reported in Loop 2420A Rendering Provider Secondary Identification. 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 504 552 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 X 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 Usage notes If sent, the Rendering Provider Taxonomy Code must match 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 505 552 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 0B XXX 2U XXX Max use 20 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. 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 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 506 552 2420A Rendering Provider Name Loop end 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 507 552 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 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 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 508 552 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 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. 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 509 552 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 510 552 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 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 XXX 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 511 552 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 512 552 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 XXXXX XXXX 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 513 552 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 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 | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_16 |
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 511 552 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 512 552 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 XXXXX XXXX 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 513 552 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 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 514 552 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 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 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 515 552 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 516 552 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 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 XXXXX XXX XX 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 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 517 552 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 518 552 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 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. 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 519 552 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 520 552 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 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 X XXXX 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 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 521 552 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 522 552 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 X 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 523 552 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 XXXXX XX XXXXXXX 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 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 524 552 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 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 525 552 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 526 552 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 XX FX XXXXX EX XX 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 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 527 552 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 528 552 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 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 XXXXXX XXXXXX XX 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. 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 529 552 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 530 552 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 XXXX 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 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 531 552 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 532 552 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 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 533 552 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 XXXXXX 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 534 552 2420G Ambulance Pick-up Location Loop end 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 XXX XX XXXXXXXX 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 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 535 552 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 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 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 536 552 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 XXX 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 537 552 2420H Ambulance Drop-off Location Loop end 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 XX XX XXXXXXXX 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 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 538 552 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 XX 000000000000 ER XXXXXX XX XX XX XX X 0000 00000000 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 539 552 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 540 552 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 541 552 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 PI X 000000000000000 0000000000000 XX 0000000 0 0000000 X 000000000000000 000000000000 XX 00000 00000 00 XXXX 00000000 0 XX 000000000 00000000000 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 542 552 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 543 552 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 544 552 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 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 | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_17 |
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 543 552 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 544 552 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 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, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 545 552 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 000 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 546 552 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 XX 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 547 552 2440 Form Identification Code Loop end 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 XXXXX Y XX 20250131 0000 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 548 552 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 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 00000 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, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 549 552 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 0000 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, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 550 552 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 Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 551 552 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. EDI Samples TMHP Sample 1 ISA 00 00 ZZ SENDER ZZ RECEIVER 240117 2150 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20240117 215049 000000001 X 005010X222A2 ST 837 0001 005010X222A2 BHT 0019 00 123456 20101212 0945 CH NM1 41 1 LASTNAME FIRSTNAME 46 111111111 PER IC TE 1111111111 NM1 40 2 TMHP 46 617591011CMSP HL 1 20 1 PRV BI PXC 1223G0001X NM1 85 2 ORGANIZATION NAME XX 1111111111 N3 100 MAIN STREET N4 TOWN TX 123456789 REF EI 111111111 HL 2 1 22 0 SBR P 18 MC NM1 IL 1 LASTNAME FIRSTNAME T MI 111111111 N3 100 MAIN STREET N4 TOWN TX 12345 DMG D8 19500211 F REF SY 111111111 NM1 PR 2 TDHS PI 617591011CMSP N4 TOWN TX 12345 CLM XXXXXX 0000000000 XX B X Y B W I P AA XX 03 1 REF G1 11111111111 NTE ADD 10 5 HI ABK XXXXX ABF X ABF XXX BF XXX BF XXXXXX ABF XXXXXX BF XXXXX BF X BF XX BF XXXXX BF XXXXXX ABF XXX NM1 82 1 LASTNAME FIRSTNAME XX 111111111 PRV PE PXC 1223G0001X LX 1 SV1 HC X XX XX XX XX XXXXXX 00000 MJ 00000000000000 XX 00 00 00 0 Y Y Y 0 DTP 472 D8 20151015 SE 30 0001 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Texas Medicaid Healthcare Partnerships (TMHP) 837 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view tmhp 837-health-care-claim-professional-x222a2a1 01HMBZ8Y6XYRFK1ZR16EKD50N6 552 552 | /kaggle/input/edi-db-835-837/Texas Medicaid and Healthcare Partnerships.pdf | 4a37daee5032a47fe649756aa1604f37 | 4a37daee5032a47fe649756aa1604f37_18 |
835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 1 Health Care Payment Advice 835 Companion Guide Refers to the ASC X12N 835 Technical Report Type 3 Guides (version 005010X221A1) Companion Guide Version Number: 1.4 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 2 Preface This Companion Guide to the ASC X12N Implementation Guides adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Blue Cross Blue Shield of Massachusetts. 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 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 3 TABLE OF CONTENTS 1. Introduction...............................................................................................................................4 1.1. Overview....................................................................................................................................... 4 1.2. References.................................................................................................................................... 4 1.3. Establishing a Trading Partnership with Blue Cross Blue Shield of Massachusetts...................... 5 2. Connecting and Communicating..................................................................................................6 2.1. Setting up your connection........................................................................................................... 6 2.2. Security......................................................................................................................................... 7 3. Testing 7 3.1. Testing Overview........................................................................................................................... 7 3.2. Test Set-up.................................................................................................................................... 7 3.3. Test Results................................................................................................................................... 8 4. Provider Support........................................................................................................................8 5. Rules and Limitations..................................................................................................................8 5.1. File Types....................................................................................................................................... 9 5.2. Tumbleweed Secure Transport..................................................................................................... 9 5.3. 835 Remittance Data Specifications............................................................................................. 9 6. Appendix..18 6.1. Revision History.......................................................................................................................... 18 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 4 1. Introduction 1.1. Overview The Health Insurance Portability and Accountability Act Administration Simplification (HIPAA- AS) requires that Blue Cross and Blue Shield of Massachusetts (BCBSMA), 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 Technical Report Type 3 (TR3) version 5010 and the Addenda (A1) for Health Care Claims Payment Advice have been established as the industry standard for the 835 HIPAA transactions. This 835 Companion Guide document supplements, but does not contradict any requirements in the ASC X12N version 5010 Implementation Guide(s) or the Addenda. This guide has been prepared as the Blue Cross and Blue Shield of Massachusetts specific 835 Companion Guide to the ASC X12N TR3. The goals of the Companion Guide are: Describe the process to become an EDI Trading Partner (Direct Submitter) with Blue Cross and Blue Shield of Massachusetts (registering as a Blue Cross Blue Shield of Massachusetts EDI Trading Partner is considered a prerequisite to receiving an 835 file directly in your Tumbleweed Outbound Folder) Describe the processes to set up, test, and make operational a Trading Partner (Direct Submitter) relationship with Blue Cross and Blue Shield of Massachusetts Clarify when conditional data elements and segments must be used with Blue Cross and Blue Shield of Massachusetts transactions and identify those codes and data elements that are not applicable to Blue Cross and Blue Shield of Massachusetts transactions. Paper PDA s will not change; they will continue to reflect values Blue Cross uses internally, not the values in the 835 transaction. 1.2. References The ASC X12N 835 (version 005010X221A1) Technical Report Type 3 guide for Health Care Claims Payment Advice has been established as the standard for Claims Payment Advisories and is available at http: www.wpc-edi.com HIPAA. The 5010 Blue Cross Blue Shield of Massachusetts 835 Companion Guide can be accessed via our Provider Portal: http: www.bluecrossma.com provider. The Adjustment Reason Codes for the remittance advice can be found at http: www.wpc- edi.com reference codelists healthcare claim-adjustment-reason-codes The Remittance Remark Codes for the remittance advice can be found at http: www.wpc-edi.com reference codelists healthcare remittance-advice-remark- codes 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 5 1.3. Establishing a Trading Partnership with Blue Cross Blue Shield of Massachusetts In order to take advantage of the transactions and communication services offered by Blue Cross Blue Shield of Massachusetts, you must execute a Trading Partner agreement. Existing Trading Partners do not need to obtain a new Trading Partner Agreement for version 5010 of the HIPAA Standard. (Reminder: As a Direct Submitter, you are required to keep your EDI contact information up to date. Email changes to EDISupport bcbsma.com.) The following process is intended for new Direct Submitters to Blue Cross Blue Shield of Massachusetts. Please refer to section 4 for EDI Support contact information. You will receive a Trading Partner Starter Kit, which will include: Trading Partner Agreement This legal document should be distributed to an Officer of the Corporation empowered to enter a contract on behalf of the Corporation. We require that two signed hard copies be delivered to us at: Blue Cross and Blue Shield of Massachusetts, Inc. Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Scott Howard 25 Technology Place Hingham, MA 02043 Trading Partner Enrollment Form A collaboration of effort from your Billing Office and Information Technology areas is suggested in order to provide accurate information. Secure File Transfer (SFTP) Account Request Form This form is used for connectivity purposes. The data provided by your Information Technology group and agents of your Billing Office is used to grant file transmission privileges. Both the Trading Partner Enrollment Form and Secure File Transfer Account Request Form can be emailed to EDISupport bcbsma.com. Please use Enrollment and Security Forms in the Subject of the e-mail. Table of Contents 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 6 2. Connecting and Communicating The purpose of this section is to identify the process for establishing connectivity to transmit and receive electronic transactions with Blue Cross and Blue Shield of Massachusetts. 2.1. Setting up your connection Providers deliver and pick up files using Blue Cross s Secure File Transfer server (Tumbleweed). We provide access to our Secure File Transfer server using the HTTPS (Hypertext Transfer Protocol Secure) scheme in order to create a secure channel via your web browser. It is important to note the differentiation between using http and https when accessing the servers. Listed below are the Blue Cross Domain Name Systems (DNS) servers for Test and Production activities. Environment DNS Test https: staging.sftp.bluecrossma.com Production https: sftp.bluecrossma.com The types of file transmissions will include: Submitting 837s Please refer to our ASC X12N 837 Health Care Claims (837) Companion Guide Retrieving 277ACKs, 999s, TA1s, Submitter Reports and Broadcast Messages Retrieving 835s New 835 Summary Report for each 835 file When we have completed processing the forms from the starter kit, you will receive: Tumbleweed mailbox and supporting directory. Tumbleweed User ID to connect your server to your Tumbleweed mailbox. Two individual User IDs for users listed in Section 4 of the Secure FTP 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. Providers using NEHEN should refer to the NEHEN Direct Claims Implementation guide to update their eClaims configuration files and, if using, the NEHEN Express Configurator. Providers using VPN to connect to us should anticipate their Change Control schedule for updates that are needed to their remote Hosts file(s) and other network configuration files. Table of Contents 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 7 2.2. Security Password reset protocol The password for your Tumbleweed account will be system generated. The password will need to be reset every 90 days. For server accounts, we will email each registered user (we register the user from the name and email address on the Security form) 3 notifications that the password is about to expire: One at 10 days before the expiration One at 5 days before the expiration One at the day of expiration. Once one registered user has visited the site to reset password, we will again email each registered user the new password. The new server password is good for the next 90 days. The user will need to update their server to use the new password. For individual User IDs, Blue Cross s Tumbleweed application will display an error message indicating your password has expired after 90 days. The message will advise you to reset your password. The Tumbleweed application provides a link to reset your password. The system will generate a new password and email the new password directly to the individual user. The new password is good for the next 90 days. The user will use the reset password button to: Reset a password after 90 days. Obtain a new password if you have forgotten your password. Unlock your accounts. Table of Contents 3. Testing 3.1. Testing Overview Testing the 835 transaction is optional. If you would like to view, retrieve, download or delete an 835 file from your test outbound Tumbleweed folder prior to production then follow the next set of steps: 3.2. Test Set-up 3.2.1. Coordinate with one of our EDI Support representatives by sending an email to EDISupport bcbsma.com 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 8 3.2.2. Submit a test 837 File to our Tumbleweed Secure FTP test server: https: staging.sftp.bluecrossma.com 3.2.3. We will process the accepted test claims. 3.2.4. We will deliver the 835s, created from claim adjudication of the 837 file, to the provider s submitter id outbound folder in the Tumbleweed Secure FTP test server. Notes: For testing purposes, the claims in your test file should simulate claims from normal business. Refer to our 837 Companion Guide for additional claim submission guidelines. 3.3. Test Results 3.3.1. Providers will be able to pick up their test 835 files via our Tumbleweed Secure FTP servers: https: staging.sftp.bluecrossma.com 3.3.2. The 835 files and corresponding 835 summary report were delivered to the provider s test Tumbleweed outbound folder. 3.3.3. The provider is able to view, retrieve, download, and delete their 835 files and corresponding 835 summary report from their Tumbleweed outbound folder. 3.3.4. The provider is able to post the 835 file to their internal system. Table of Contents 4. Provider Support If you cannot find the answers to your questions within this Companion Guide, please use the contact information below to reach the appropriate support area. EDI Support For technical questions or help related to 835 transactions, please contact: Phone: 800-771-4097 Email: EDISupport bcbsma.com Provider Central (provider portal) Provider Central provides information regarding our products, policies and procedures, as well as Companion Guides for various electronic transactions. Please refer to online documentation for the most up-to-date materials. Website: http: www.bluecrossma.com provider Email: ProviderCentral bcbsma.com Table of Contents 5. Rules and Limitations 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 9 5.1. File Types This section describes the two different types of 835 remittance files that could be delivered to a provider s outbound folder in Tumbleweed: 835 remittance file 835 Summary Report (PDF) Report Naming Convention for the 835 File Report Description 835 BCBSMA. Submitter ID.ClaimPayment. datetime.835 This file contains electronic remittance advices (ERAs) that are considered in balance. 835 Summary Report BCBSMA.(SubmitterID).SummaryReport.2011100110112419 209662.PDF This report is a summary of information contained within the 835 remittance. Table of Contents 5.2. Tumbleweed Secure Transport Each 835 Remittance file and corresponding 835 Summary Report (PDF) will be delivered directly to an assigned Tumbleweed Secure Transport outbound folder based on the provider Trading Partner Submitter Id and can be resent upon request. Each 835 Remittance File and corresponding 835 Summary Report (PDF) will be stored internally at Blue Cross and can be resent upon request. If there are questions regarding the format or content of the 835, please contact the EDI Support Team at EDISupport bcbsma.com. 5.3. 835 Remittance Data Specifications 5.3.1. Header Data 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 10 Segment ID Element ID Data Element Name Blue Cross Business Rule ISA Interchange Control Header 12 Interchange Control Version Number 00501 GS Functional Group Header 02 Application Sender s Code 00200 03 Application Receiver s Code Blue Cross-assigned Submitter ID 08 Version Release Industry Identifier Code This field will be mapped with the following value: 005010X221A1 Table of Contents 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 11 5.3.2. Loop Specific Data Loop ID Segment Element ID Data Element Name Blue Cross Business Rule TRN Re-association Trace Number 02 Reference Identification One of the following trace numbers will be mapped to the 835 in field TRN 02. For Paid 835s: 1. BCBSMA Check Number TRN 1 123456789 1041045815 2. BCBSMA EFT Number TRN 1 987654321 1041045815 For Non Check 835s: 1. NONCHECK 835 ( zero paid or denied) TRN 1 NC08225000712 1041045815 2. ENCOUNTER 835: (capitation) TRN 1 EN08225000712 1041045815 3. DENTAL PRETREATMENT 835: TRN 1 PT08225000712 1041045815 Note: The formula for the new non check, encounter and pretreatment trace number is: Qualifier: NC (non check), EN(encounter), or PT(pretreatment) Year (YY) Julian date (JJJ) 6-digit sequence number 1000A PER Payer Business Contact Information 02 Payer Business Name BLUE CROSS BLUE SHIELD OF MASSACHUSETTS 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 12 Loop ID Segment Element ID Data Element Name Blue Cross Business Rule 03 Communication Number Qualifier TE (telephone) 04 Communication Number 8007714097 PER Payer Technical Contact Information 02 Payer Technical Name BLUE CROSS BLUE SHIELD OF MASSACHUSETTS 03 Communication Number Qualifier EM (Electronic Mail) 04 Communication Number EDISUPPORT BCBSMA.COM 1000A N1 Payee Identification 03 Identification Code Qualifier BCBSMA will return XX (NPI) or if billing provider is not eligible for NPI BCBSMA will return FI (Federal Tax ID). 04 Identification Code If the billing provider NPI is on file with BCBSMA then N1 04 will be mapped with the billing provider NPI. 1000B REF Additional Payer Identification Reference 01 Reference Identification Qualifier This reference segment will map the Tax ID for those providers who have an NPI and a Legacy ID for those not eligible to obtain an NPI. If the billing provider NPI is on file then REF 01 will be mapped with a qualifier of TJ. If the billing provider is not eligible to obtain an NPI then BCBSMA will map REF 01with a qualifier of PQ. 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 13 Loop ID Segment Element ID Data Element Name Blue Cross Business Rule 02 Reference Identification If the billing provider s NPI is coded in field N1 04 then this Additional Payer Identification Reference Segment will be coded with the billing provider s Tax ID. If the billing provider is not eligible to obtain an NPI then this Additional Payer Identification Reference Segment will be coded with the billing provider s Legacy ID. 2100 CLP Claim Payment Information 01 Claim Submitter s Identifier Patient Control Number received on the original claim. 02 Claim Status Code Values used by Blue Cross 1 Processed as Primary 2 Processed as Secondary 4 Eligibility denial when the patient is not a BCBSMA member. 22 Reversal of Previous Payment Note: Group Code CR was removed in 5010 and will not be returned for claim reversals. 25 Predetermination Pricing Only No Payment 06 Claim Filing Indicator Blue Cross will default to the value of 12 for all claim types. Note: A default value of 12 was assigned to this field because the submitted 837 value of BL (Blue Cross Blue Shield) is not considered a valid value for the 835. 07 Reference Identification (Payer Claim Control Number) Blue Cross ICN for adjustments: Note 1: The reversal side of the adjustment will map the claim number the adjustment was initiated from to CLP07. Note 2: The positive side of the adjustment will also include the claim number the 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 14 Loop ID Segment Element ID Data Element Name Blue Cross Business Rule adjustment was initiated from in a subsequent REF-Other Claim Related Identification segment. 2100 CAS Claim Adjustment 01 Claim Adjustment Group Code Claim Adjustment Segment (CAS) Note: BCBSMA reports the CAS segments at line level (loop 2110) not claim level (loop 2100). 2100 NM1 Corrected Patient Insured Name 03 Name Last or Organization Name This field is mapped when we have determined that the Insured Last Name submitted on the claim is different from the one we have in our internal Eligibility Files. Note: If the Corrected Insured Last Name is different from what you have on file for this member please update your records. 04 Name First This field is mapped when we have determined that the insured first name submitted on the claim is different from the one we have in our internal Eligibility Files. Note: If the Corrected Insured First Name is different from what you have on file for this member please update your records. 05 Name Middle This field is mapped when we have determined that the insured Middle Initial submitted on the claim is different from the one we have in our internal eligibility files. Note: 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 15 Loop ID Segment Element ID Data Element Name Blue Cross Business Rule If the Corrected Insured Middle Initial is different from what you have on file for this member please update your records. 07 Name Suffix If the Insured Last Name includes a suffix then we will concatenate the suffix to the insured s last name. 09 Identification Code Corrected Insured ID This field is mapped when the Insured Identification Number submitted on the claim is different from what we have in our internal Eligibility File. Note: If the Corrected Insured Identification Number is different from what you have on file for this member please update your records. 2100 REF Other Claim Related Identification Reference Identification Added reference segment to the positive side of the adjustment claim information in order to identify the claim number an adjustment was initiated from. 2100 DTM Coverage Expiration Date 02 Date Member s cancelled date. 2100 DTM Claim Received Date 02 Date Date Blue Cross received the claim. 2110 SVC Service Payment Information 06 Composite Medical Procedure Identifier Submitted Procedure Code This field is mapped when the procedure code has been changed from what was submitted on the claim. 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 16 Loop ID Segment Element ID Data Element Name Blue Cross Business Rule 07 Quantity Submitted Units of Service This field is mapped when the units of service have been changed from what was submitted on the claim. Note: We will also populate this field when anesthesia services have been billed because our claims adjudication system converts the time information submitted on the claim to units needed for internal claims processing. 2110 CAS Service Adjustment 01 Claim Adjustment Group Code HIPAA CAS Coding The Service level CAS segment will include a HIPAA group code, adjustment reason code, and remark code (if applicable) as well as an amount. Note 1: CAS coding indicates how a line has been processed by BCBSMA. Note 2: Please refer to the following web site for valid adjustment reason and remark codes: http: www.wpc-edi.com reference Note 3: Valid Group Codes are: CO PR PI OA 2110 REF Rendering Provider Information 01 Reference Identification Qualifier Rendering Provider Information: 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 17 Loop ID Segment Element ID Data Element Name Blue Cross Business Rule If the rendering provider NPI is on the submitted claim then REF01 will be mapped with a qualifier of HPI. If the rendering provider is not eligible to obtain an NPI then we will map REF 01with a qualifier of IA. 02 Reference Identification Code Rendering Provider Information: The rendering provider NPI will be mapped to REF 02. If the rendering provider is not eligible to obtain an NPI their Blue Cross Legacy ID will be mapped to REF 02. PLB Provider Adjustment 01 Reference Identification Provider Level Adjustment: If the Billing Provider Identification Code (Loop 1000B N104) is populated with a NPI then the PLB Reference Identification will be coded with the billing provider s 10- digit NPI. If a billing provider is not eligible to obtain an NPI then the PLB Reference Identification will be coded with the billing provider s Legacy ID. 03-2 Reference Identification This field will map the BCBSMA account receivable number and the associated provider patient account number. (Separated by a space) 835 BLUE CROSS BLUE SHIELD OF MASSACHUSETTS COMPANION GUIDE Blue Cross Blue Shield of Massachusetts, July 2020 18 6. Appendix 6.1. Revision History Revision Number Date Section Notes 1.2 5 22 2017 1.3 Replacing Kim Hoff s contact information with Scott Howard s 5.1 Removed from File Types: In balance 1.3 3 23 2018 5.1 Removed from File Types: Out of balance 1.4 7 21 2020 1.3 Added reminder: As a Direct Submitter, you are required to keep your EDI contact information up to date. Email changes to EDISupport bcbsma.com. 4 Added Provider Central email address: ProviderCentral bcbsma.com MPC_032417-2F | /kaggle/input/edi-db-835-837/MPC_032417-2F___835_Companion_Guide.pdf | 9dec2ec60020682cd76e6a05177cbe17 | 9dec2ec60020682cd76e6a05177cbe17_0 |
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 837 Health Care Claim: Professional (X222 A2 A1) 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 1 665 View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view anthem health-care-claim-professional- x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 POWERED BY Build EDI implementation guides at stedi.com 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 DTP 1350 Date - Last Worked Max use 1 Optional 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 12 665 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 13 665 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 14 665 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 Other Payer Referring Provider Loop 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 15 665 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 CRC 4500 Hospice Employee Indicator Max use 1 Optional 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 16 665 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 NTE 4850 Line Note Max use 1 Optional 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 17 665 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 18 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 2330 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 22 665 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HC XXX XXX 20250131 2102 00 X 005010X222A1 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) 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 23 665 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 005010X222A1 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 005010X222A1 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. 005010X222A1 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX 20250131 0733 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. 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX XX 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX EM XXX EM XXXXX FX 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 31 665 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 ANTHEM BLUE CROSS 46 24375 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 ANTHEM BLUE CROSS WESTERN GROWERS 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 32 665 1000B Receiver Name Loop end Heading end 24375 Western Growers 47198 Anthem Blue Cross 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 34 665 PRV 0030 Detail Billing Provider Hierarchical Level Loop PRV Billing Provider Specialty Information | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_0 |
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 ANTHEM BLUE CROSS 46 24375 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 ANTHEM BLUE CROSS WESTERN GROWERS 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 32 665 1000B Receiver Name Loop end Heading end 24375 Western Growers 47198 Anthem Blue Cross 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX 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 Enter the taxonomy code to uniquely identify the provider. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 USD 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 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. USD US Dollar 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 1 XX XXXXX XXXXXX XXXXXX 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX X Max use 1 Required N3-01 166 Billing Provider Address Line Min 1 Max 55 String (AN) Required Address information Usage notes Enter the physical address to uniquely identify the provider. N3-02 166 Billing Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 40 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 EI XX 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. 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 1G 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX EM XXXXXX EM XXX TE 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Usage notes Enter the address to uniquely identify the provider. If payment expected to be remitted to PO Box Lock Box, submit in Pay-to loop. Example N3 XXXXX X Max use 1 Required N3-01 166 Pay-To Address Line Min 1 Max 55 String (AN) Required Address information Usage notes Pay-to Provider Address Line N3-02 166 Pay-To Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX XX XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 48 665 2010AB Pay-to Address Name Loop end 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX XV 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Usage notes Enter the physical address to uniquely identify the provider. Example N3 XXX XXXXXX Max use 1 Required N3-01 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Required Address information Usage notes Pay-to Plan Organizational Name N3-02 166 Pay-To Plan Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXXX 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Usage notes Pay-to Plan Tax 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 56 665 0 No Subordinate HL Segment in This Hierarchical Structure. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 S 18 X XXXXXX 42 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) 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 59 665 ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X 01 0000000 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 61 665 For this implementation, the listed value takes precedence over the semantic note. Y Yes 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX XX XXXX XXXXXX 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Usage notes ALL ALPHA CHARACTERS MUST BE IN UPPERCASE LETTERS. Code Enter the ID Number exactly as it appears on the front of the ID card, including ANY PREFIX. Unless requested, do not send SSN 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX XX XXXXXXX 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 66 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX TE X 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 WESTERN GROWERS PI 24375 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 Usage notes ANTHEM BLUE CROSS Identifies receiver WESTERN GROWERS if file is known to contain Western Growers, exclusively ANTHEM BLUE CROSS WESTERN GROWERS 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 73 665 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 NM1-09 67 Payer Identifier String (AN) Required Code identifying a party or other code 24375 Western Growers 47198 Anthem Blue Cross 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X XX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 75 665 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N4 Payer City, State, ZIP Code To | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_1 |
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 WESTERN GROWERS PI 24375 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 Usage notes ANTHEM BLUE CROSS Identifies receiver WESTERN GROWERS if file is known to contain Western Growers, exclusively ANTHEM BLUE CROSS WESTERN GROWERS 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 73 665 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 NM1-09 67 Payer Identifier String (AN) Required Code identifying a party or other code 24375 Western Growers 47198 Anthem Blue Cross 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X XX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 76 665 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 G2 XXXXX 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. 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 00000000000000 XX B X N C Y Y P AA X X XX XX 09 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 81 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 82 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 83 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 85 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 87 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 89 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 93 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 360 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 97 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 99 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 103 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 107 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 109 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 111 665 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 113 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 111 665 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 113 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 115 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 PN AA AC XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 05 00000000000000 000 XXXXXX 0 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 0000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 125 665 The value carried in this element is limited to a maximum of 20 positions. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 String (AN) Required Min 1 Max 50 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 127 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 135 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 137 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 140 665 6 Request for Override Pending 7 Special Handling 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 000000000 E DH 0000 XXXX XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 N 08 XXX XX 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 N S2 XXX 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. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 E3 Y L1 XXX XX XX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 E3 Y L1 XXX XX XX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX BG XXXX BG XXXXX BG XX BG XXXXX BG X X BG XXXXX BG XXXX BG XXXXX BG XXXX BG X BG XXXX X 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX ABF XXXXX ABF XXXX ABF X ABF X ABF X X BF XXXX BF X ABF XXXXX ABF XXX BF XXXXXX ABF XX XXXX 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 Max use 1 Optional 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 162 665 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 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, 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 163 665 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-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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 164 665 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-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. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 165 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 166 665 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 167 665 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-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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 168 665 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, 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 00 000000 0000000000 X 0 XXXXXX 0000000000000 00 T1 4 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X XXXXXX XXXXX XX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 1G XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 1 X 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 180 665 NM1-03 1035 Laboratory or Facility Name Min 1 Max | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_4 |
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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX XX XXXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 183 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 G2 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XX XXXXXX XX XXXX 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX XX XXXXXXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 193 665 2310E Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 197 665 2310F Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 S 39 XXXXX XXXXX 12 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 PI XXXXX 00000000000 000000000000000 XXXX 0 0 000000 XX 0000 0 X 000 000000000000000 XXXX 00000 000 0000000 XX 00000000 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 Max use 5 Optional 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 0000000000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 0000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Y 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 0000 0000000 XX X XXXXX XXXX XX 000 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX XXXX XXXXX XXX 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX XXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX XX XXX 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 216 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_5 |
implementation guide, do not send. Example N4 XXXX XX XXX 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 216 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX XX XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 222 665 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 230 665 1 Person 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 G2 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 LU 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX XX XX XX XX XXXXX 000000000 MJ 00000 000 X 0 00 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX DA 000000 000000000000 0000000000 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 10 AA AC XXXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_6 |
BR Benchmark Testing Results 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 0000 B DH 000 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 000000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 N 05 XX XX XXX XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 38 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 258 665 Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 260 665 65 Open This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 00000000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 OG R4 000000000000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 04 0000000000 000000 XXX 000000 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_7 |
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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 0000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 01 000000000000000 0000 XXXXXX 00000 XXXX 00 ER XXXXX UN 0000 T3 2 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 ON 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 00000000000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 303 665 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 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 XXXXXX XXXXXX XXXXX XX XX XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 1G XXXXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 Code identifying the country subdivision Usage notes 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 316 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XX XXX XX XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 LU XXXXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX X XX XXXXXX 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_8 |
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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX X XX XXXXXX 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXXX XX XXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 327 665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X TE XXXXX FX XXXX TE 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 DN 1 X XX XXXX XXXX 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 0B XXXX 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXXX XX XXXXXXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX XX XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XX 00000000000000 HC XXX XX XX XX XX X 00000 0 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 OA XXX 00000 00 XXXXX 00000000 000000000000 X XXXX 000000 000 X 000000000 0000 XXXX 0000 00000 0 XXXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 AS XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XX W XXXXX 20250131 0000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 357 665 0 No Subordinate HL Segment in This Hierarchical Structure. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X XXXXX XX 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 | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_9 |
whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 357 665 0 No Subordinate HL Segment in This Hierarchical Structure. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X XXXXX XX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX XX XXXXXXXX XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 365 665 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 XXXX TE XXXXX EX XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 366 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 367 665 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 XXXXX 00 X B X Y B Y I P AA XXX XX XXX 05 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. Maximum of 20 alphanumeric characters. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 368 665 Value is returned on outbound 835 and other transactions. 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. Value must equal the sum of submitted service line charges in Loop 2400 SV102. 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. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 369 665 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. 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 370 665 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. 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 Code identifying the country 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 371 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 372 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 373 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 374 665 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 XX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 375 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 376 665 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 XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 377 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 378 665 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 090 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 379 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 380 665 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 381 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 382 665 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 314 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 383 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 384 665 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 385 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 386 665 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 387 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 388 665 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 389 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 390 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 391 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 392 665 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 393 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 394 665 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 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 395 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 396 665 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 397 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 398 665 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 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 | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_10 |
Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 396 665 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 397 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 398 665 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 399 665 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 400 665 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 401 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 402 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 403 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 404 665 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 V5 BM AC XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 405 665 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 BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 406 665 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. Providers using mail fax, submit the 151 Adjustment Request Form with the supporting documentation. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 407 665 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 05 0000 000000 XX 000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 408 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 409 665 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 00000000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 410 665 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 XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 411 665 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 XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 412 665 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 XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 413 665 Will be returned on EBR and or DPR, if submitted. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 414 665 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 XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 415 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 416 665 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 417 665 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 418 665 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 419 665 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 420 665 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 421 665 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 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 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 Usage notes Claim Original Reference Number 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 422 665 Represents the original claim indicated on the 835 when Loop 2300, CLM05-3 equals values of '7' or '8' 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 429 665 6 Request for Override Pending 7 Special Handling 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 ADD 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 000 B DH 00000000 XXX XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 A X X 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Y 09 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 N S2 XXX 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 | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_11 |
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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 N S2 XXX 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. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 E1 N L3 XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XX 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX BG XX BG XXX BG XXXXX BG XXXX BG XXXX X BG X BG XXXXX BG X BG X BG XXXX 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX ABF XXXXXX BF XXX ABF X BF XXXXX ABF X XXX BF XXXXX ABF XXXXX BF XXXX ABF XXXXXX ABF XXX XX ABF XXXX 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 Max use 1 Optional 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 451 665 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 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, 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 452 665 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-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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 453 665 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-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. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 454 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 455 665 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 456 665 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-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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 457 665 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, 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 00000000000000 0000000000000 XXXX 000 X X 0 T1 1 4 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX XX X XXXX XX XXXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 1G 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX XXXXXX XX XXXXX XX XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX Max | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_12 |
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 XXXX XXXXXX XX XXXXX XX XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXXX XX XXXXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 472 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX TE XX EX XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX XXXXX XXXXXX XX XX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 D 39 XXXX XXXXXX 41 13 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 CR X 000000000000000 000 XXXXX 0000000000000 0 00000000000 XXXX 0000000000000 000000 XXXXX 000 00 00000000000000 X 000 000 XXX 000000000000 0000 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 Max use 5 Optional 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 00000000000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 00 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Y 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 0000000 000 X XXX XXXX XX XXXXX 000000000000 0 0000000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 1 XX X X XXXX MI 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_13 |
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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 1 XX X X XXXX MI 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX XXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 505 665 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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. Unless requested to not send SSN (SY Social Security Number) Example REF SY XXXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Unless requested to not send SSN (SY Social Security Number) 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX XX XXXXXXX 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 511 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 519 665 1 Person 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 522 665 1 Person 2 Non-Person Entity 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 LU XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 1G 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. 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 529 665 1 Person 2 Non-Person Entity 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 IV XXXXXX XX XX XX XX XXXX 0000 MJ 0000000000 00000 X 00 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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. Sum of service line charges must equal the Total Claim Charge Amount in Loop 2300 CLM02. 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 535 665 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 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 536 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX DA 000000000000000 00000000000 00 0 1 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_14 |
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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX DA 000000000000000 00000000000 00 0 1 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 AD 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 04 AA 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 D DH 00000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 I MO 00000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Y 38 XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 549 665 Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 551 665 65 Open This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 - 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 Usage notes Both "From Date" and "To Date" are required when place of service is 22 or 23. 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 560 665 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 - 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 00000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 000000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 TR R4 000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 01 000000 00000 XXXX 0000 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_15 |
25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 2U 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 00000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 0000000000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX 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 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 Usage notes When billing unlisted HCPCS (NOC codes) in Loop 2400 SV202-2 (Procedure Code), include the drug and dosage 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX 0000000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 14 00 0000000000000 XXXXXX 000000000 XXX 0000 0000 HC XX UN 0000000000000 T2 2 5 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 EO 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Usage notes NDC for prescribed drugs and biologics when required by government regulation. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 1 X XXXXX XXXXX XXXXXX XX XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Usage notes Enter the taxonomy code to uniquely identify the provider. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 2 XX XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 607 665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 G2 XXXXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_16 |
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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 607 665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 G2 XXXXX 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX XXXX X XXXXXX XX XX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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. 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XX X XXX X 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 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX XXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXXX XX XXXXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 618 665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX EM XX EM XX FX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXX XXX 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. 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XX XXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 X X 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXX 00 WK XXXXX XX XX XX XX X 0000 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. Service Line Paid Amount 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 CR XXX 000 000000000000 XXXXX 0 00000000000 0 XXXX 0000000 000000 XXXX 000 000000 XXXX 000000 00000000 000 XXXXX 000000 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXXXX 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_17 |
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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 XXX W XXXXXX 20250131 0000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 00000 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 648 665 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 0 000 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 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 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 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 650 665 EDI Samples Example 1: Commercial Health Insurance ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1408 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 140840 000000001 X 005010X222A1 ST 837 0021 005010X222A1 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 ANTHEM BLUE CROSS 46 47198 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 ANTHEM BLUE CROSS PI 24375 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 651 665 Example 10a: Drug administered in the Physician Office ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1411 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 141104 000000001 X 005010X222A1 ST 837 0711 005010X222A1 BHT 0019 00 0013 20040801 1200 CH NM1 41 2 Associates in Medicine 46 587654321 PER IC Bud Holly TE 8017268899 NM1 40 2 ANTHEM BLUE CROSS 46 47198 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 ANTHEM BLUE CROSS PI 24375 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 652 665 Example 11: PPO Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1415 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 141535 000000001 X 005010X222A1 ST 837 1002 005010X222A1 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 WESTERN GROWERS 46 24375 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 WESTERN GROWERS PI 24375 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 653 665 Example 12: Out of Network Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1416 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 141631 000000001 X 005010X222A1 ST 837 1024 005010X222A1 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 WESTERN GROWERS 46 24375 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 WESTERN GROWERS PI 24375 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 654 665 Example 2: Encounter ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1418 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 141815 000000001 X 005010X222A1 ST 837 0021 005010X222A1 BHT 0019 00 0123 20061015 1023 CH NM1 41 2 PREMIER BILLING SERVICE 46 TGJ23 PER IC JERRY TE 3055552222 EX 231 NM1 40 2 ANTHEM BLUE CROSS 46 47198 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 ANTHEM BLUE CROSS PI 47198 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 655 665 Example 3a: Claim from Billing Provider to Payer A ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1420 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142058 000000001 X 005010X222A1 ST 837 0021 005010X222A1 BHT 0019 00 0123 20051015 1023 CH NM1 41 2 PREMIER BILLING SERVICE 46 TGJ23 PER IC JERRY TE 3055552222 NM1 40 2 WESTERN GROWERS 46 24375 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 WESTERN GROWERS PI 24375 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 656 665 SE 52 0021 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 657 665 Example 4: Medicare Secondary Payer (COB) ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1421 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142142 000000001 X 005010X222A1 ST 837 0002 005010X222A1 BHT 0019 00 000001142 20050214 115101 CH NM1 41 2 SPECIALISTS 46 1111111 PER IC SUE TE 8005558888 NM1 40 2 ANTHEM BLUE CROSS 46 47198 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 ANTHEM BLUE CROSS PI 47198 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 658 665 Example 5: Ambulance ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1422 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142212 000000001 X 005010X222A1 ST 837 000017712 005010X222A1 BHT 0019 00 000017712 20050208 1112 CH NM1 41 2 AAA AMBULANCE SERVICE 46 376985369 PER IC LISA SMITH TE 3037752536 NM1 40 2 WESTERN GROWERS 46 24375 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 WESTERN GROWERS PI 24375 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 659 665 SE 52 000017712 GE 1 000000001 IEA 1 000000001 1 30 25, 11:53 AM Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 660 665 Example 6: Chiropractic ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1422 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142242 000000001 X 005010X222A1 ST 837 3701 005010X222A1 BHT 0019 00 007227 20050215 075420 CH NM1 41 2 DAVID GREEN 46 S01057 PER IC KATHY SMITH TE 4105558888 NM1 40 2 ANTHEM BLUE CROSS 46 24375 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 ANTHEM BLUE CROSS PI 47198 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 661 665 Example 7: Oxygen ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1423 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142340 000000001 X 005010X222A1 ST 837 0001 005010X222A1 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 WESTERN GROWERS 46 24375 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 WESTERN GROWERS PI 24375 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 663 665 Example 8: Wheelchair ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1424 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142406 000000001 X 005010X222A1 ST 837 112233 005010X222A1 BHT 0019 00 16 20050326 1036 CH NM1 41 2 XYZ WHEELCHAIRS INC 46 ABC55 PER IC JANE TE 2225551111 NM1 40 2 ANTHEM BLUE CROSS 46 47198 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 ANTHEM BLUE CROSS PI 47198 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 664 665 Stedi is a registered trademark of Stedi, Inc. 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Example 9: Anesthesia ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1424 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142432 000000001 X 005010X222A1 ST 837 0001 005010X222A1 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 WESTERN GROWERS 46 24375 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 WESTERN GROWERS PI 24375 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 Anthem 837 Health Care Claim: Professional (X222 A2 A1) - Stedi EDI Guides https: www.stedi.com app guides view anthem health-care-claim-professional-x222a2a1 01HQWSSVRA6JCGWW921V01R8Q7 665 665 | /kaggle/input/edi-db-835-837/Anthem 837 Health Care Claim_ Professional.pdf | 8e700075e4560870ffc5854319277205 | 8e700075e4560870ffc5854319277205_18 |
Stedi maintains this guide based on public documentation from United Healthcare. Contact United Healthcare 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 united-healthcare health-care-claim-paymentadvice- x221a1 01H16GHN4XE0BAD19HPZ89CPVM POWERED BY Build EDI implementation guides at stedi.com 1 29 25, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 1408 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 7 128 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HP XXX XXXXX 20250130 0704 0000 XX 005010X221A 1 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 I 0000000000 C FWT CCP 04 XXXXXX DA XX XXXXXX XXXX XXXXXXXXX 01 XXX DA XX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 XXXX 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 XXXXX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 X 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 XXXXXX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 22 128 N3 1000 Heading Payer Identification Loop N3 Payer Address To specify the location of the named party Example N3 XXXXXX XX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 XXXXXX TE XXXX TE XXXXX EX XX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 XXXXXX UR X UR 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 XXXXXX FI XXXXXX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 XXX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 XXXXXX XX XXXX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 FT XXXXXX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 36 128 1000B Payee Identification Loop end Heading end Contains URL web address | /kaggle/input/edi-db-835-837/United Healthcare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 9fe13e2754b5660598d073678ffd871b | 9fe13e2754b5660598d073678ffd871b_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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 FT XXXXXX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 36 128 1000B Payee Identification Loop end Heading end Contains URL web address or e-mail address. 1 29 25, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 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 29 25, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 XX XX 20250130 00000000 000 000000000 00000 0000000000 0000000000000 00000000000000 0 00000000000000 000000000000000 00000000 0000000 000000 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 41 128 See TR3 note 3. 1 29 25, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 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 000000 0000000000 00000000 00 0000 00000 000 00000 000000 000000000000 0 000000 00000000 0000000000 0000 0 00000000 0000000000 00 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 43 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 44 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 45 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 XX 3 0000000000 00000000000 0000000000000 M C X X X XX 00000 00 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 OA XXX 00000000000000 00 X 000000000000000 00 000000 XXXX 00000 000 X 000000000 00000 XXXXX 000 0 000 XXX 000 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 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 55 128 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 XX XXXX XXXXX X 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 57 128 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 XXXXX NI XX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 58 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 59 128 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 XXXXX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 60 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 61 128 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 X XXXXX XXXXX X MI 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 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 62 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 63 128 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 XXXX XXX XXXXXX II XX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 64 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 65 128 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 XXXXXX XXX XXXX 34 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 66 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 67 128 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 XXX X XXXXXX XXX BD 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 68 128 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 | /kaggle/input/edi-db-835-837/United Healthcare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 9fe13e2754b5660598d073678ffd871b | 9fe13e2754b5660598d073678ffd871b_1 |
Optional Individual middle name or initial 1 29 25, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 66 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 67 128 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 XXX X XXXXXX XXX BD 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 68 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 0000 00000000 00000 0000000 XXXXXX 00000000 0 00000 000000 00 00 0 000 000000000000 0000000 000 00 00000000 0000000000 000000000 00000000 XX XXXX X XXXX XXXXX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 70 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 71 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 72 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 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 000000000 0000000000 XX XXXXX XXXXX XXXXX XXX XX 000000000000000 000000000000 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 74 128 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 XX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 G2 X 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 78 128 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 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 80 128 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 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 XXXXX TE XXX EM XX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 I 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 OU 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 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 N4 XXXXXX XX XX XX XX 0 00000 XXX 000000 HP X XXXX XX XX XX XX XX 00000000000 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 472 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 00000000000 0000000000000 XXXX 000 0 000000000 X 00000000000000 000000000000000 XX 0 000000000 0000000 XXXXX 00000000000 000000000 0 X 0000000 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 97 128 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 | /kaggle/input/edi-db-835-837/United Healthcare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 9fe13e2754b5660598d073678ffd871b | 9fe13e2754b5660598d073678ffd871b_2 |
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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 97 128 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 XXXX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 D3 XXX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 100 128 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 APC XX 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 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. 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 ZO 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 XXXXX 20250130 RE XXXXX 000000000000 XX XX 00 000 XX XXXX 000000000000000 XX XXXX 00 XX XXXXX X 00000000000 XX XXXXXX 00000000000 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 00000 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 112 128 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 29 25, 8:52 PM United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 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 United Healthcare 835 Health Care Claim Payment Advice (X221A1) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-paymentadvice-x221a1 01H16GHN4XE0BAD19HPZ89CPVM 128 128 | /kaggle/input/edi-db-835-837/United Healthcare 835 Health Care Claim Payment_Advice (X221A1) - Stedi EDI Guides.pdf | 9fe13e2754b5660598d073678ffd871b | 9fe13e2754b5660598d073678ffd871b_3 |
Security Health Plan 837 Companion Guide (Institutional) 1 Companion Guide Health Care Claim 837 Companion Guide Institutional Refers to the ASC X12N 837 Technical Report Type 3 Guide (Version 005010X223A2) November 2022 Security Health Plan 837 Companion Guide (Institutional) 2 Disclosure Statement It is the sole responsibility of the provider vendor to initiate all transactions. Health plans are dynamic; the data included in these transactions is deemed true and accurate only at the particular time of the transaction. Any questions regarding the data should be directed to the Security Health Plan Provider Relations department for claims and or remittance data. Security Health Plan 837 Companion Guide (Institutional) 3 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 Security Health Plan. 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 Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. Security Health Plan 837 Companion Guide (Institutional) 4 Editor s Note: This page is blank because major sections of a book should begin on a right hand page. Security Health Plan 837 Companion Guide (Institutional) 5 Table of Contents 1 INTRODUCTION........................................................................................................................................................ 6 Scope....................................................................................................................................................................................... 6 Overview................................................................................................................................................................................. 6 References.............................................................................................................................................................................. 6 Additional Information............................................................................................................................................................. 6 2 GETTING STARTED..................................................................................................................................................... 6 Working with Security Health Plan........................................................................................................................................ 6 Trading Partner Registration................................................................................................................................................. 6 Certification and Testing Overview......................................................................................................................................... 6 3 TESTING WITH THE PAYER......................................................................................................................................... 6 4 CONNECTIVITY WITH THE PAYER COMMUNICATIONS............................................................................................... 7 Process Flows.......................................................................................................................................................................... 7 Transmission Administrative Procedures............................................................................................................................. 7 Re-Transmission Procedure................................................................................................................................................... 7 Communication Protocol Specifications................................................................................................................................. 7 Passwords............................................................................................................................................................................... 8 5 CONTACT INFORMATION.......................................................................................................................................... 8 EDI Customer Service................................................................................................................................................................. 8 EDI Technical Assistance......................................................................................................................................................... 8 Provider Service Number........................................................................................................................................................ 8 Applicable Websites E-Mail...................................................................................................................................................... 8 6 CONTROL SEGMENTS ENVELOPES............................................................................................................................. 8 ISA-IEA..................................................................................................................................................................................... 8 GS-GE.................................................................................................................................................................................... 10 ST-SE...................................................................................................................................................................................... 11 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS................................................................................................ 12 8 ACKNOWLEDGEMENTS AND OR REPORTS................................................................................................................ 12 Report Inventory................................................................................................................................................................... 12 9 TRADING PARTNER AGREEMENTS........................................................................................................................... 12 Trading Partners................................................................................................................................................................... 12 10 TRANSACTION SPECIFIC INFORMATION.................................................................................................................. 12 APPENDICES............................................................................................................................................................... 16 Implementation Checklist..................................................................................................................................................... 16 Business Scenarios................................................................................................................................................................ 16 Transmission Examples......................................................................................................................................................... 16 Frequently Asked Questions................................................................................................................................................. 16 Change Summary.................................................................................................................................................................. 16 Security Health Plan 837 Companion Guide (Institutional) 6 1 INTRODUCTION Scope This Companion Guide has been designed to describe to Security Health Plan s trading partners the format and data content of the Health Care Claims: Institutional 837 transaction set in the Electronic Data Interchange (EDI) environment. The 837 claims transaction is used to convey information related to institutional claims and or encounters. Overview The Council for Affordable and Quality Healthcare (CAQH) created the Committee on Operating Rules for Information Exchange (CORE). This committee established a common set of operating rules for health care systems which allow providers and other health care systems to implement the CORE operating rules. References For more information regarding the ASC X12 Standards for Electronic Data Interchange and to purchase copies of the TR3 documents, consult the Washington Publishing Company web site at http: www.wpc-edi.com. The CORE Phase operating rules are located on the CAQH web site at http: www.caqh.org. Additional Information Assumes the provider vendor initiates all transactions. 2 GETTING STARTED Working with Security Health Plan Questions related to the 837 transactions should contact Security Health Plan s Provider Relations department at 715-221-9640 or shpprd securityhealth.org. Trading Partner Registration All providers who want to send 837 transactions should contact Security Health Plan s Provider Relations department at 715-221-9640 or shpprd securityhealth.org. Certification and Testing Overview Testing with the payer is required. You must contact the payer prior to sending all transactions. 3 TESTING WITH THE PAYER Prior to exchanging any production transactions with Security Health plan, you must first exchange test transactions by contacting Security Health Plan s Provider Relations department at 715-221-9640 or shpprd securityhealth.org. The Provider Relations department will work with you to ensure that testing has been verified and completed at which time you will be notified that your future transactions will be treated as production. All test transactions are to be sent in a separate file from normal production transactions. All ASC X12 transactions must use ISA15 (Usage Indicator) to signal whether the data enclosed in the interchange envelope is test or production. Security Health Plan 837 Companion Guide (Institutional) 7 4 CONNECTIVITY WITH THE PAYER COMMUNICATIONS Process Flows This process flow shows a high level overview of trading partner connectivity to Security Health Plan and illustrates the methods used for connectivity. SFTP Process Flow SHP Trading Partner SFTP Batch (asynchronous) transactions Trading Partner SFTP SHP X12 837 Claims X12 837 Claims Transmission Administrative Procedures Enrolled Security Health Plan trading partners will submit X12N 837 transaction data to Security Health Plan for processing. Security Health Plan validates submission of X12N format(s) and processes the transaction data through the claim adjudication system. Re-Transmission Procedure Transmission Production Issues When file transmission or technical production issues occur, which could require the re-submission of files, please contact Security Health Plan s Provider Relations department at 715-221-9640. Communication Protocol Specifications SHP Secure EDI Portal The SHP Secure EDI Portal allows a trading partner to post and retrieve files. A trading partner must be an authenticated portal user. The trading partner accesses the SHP Secure EDI Portal from a web browser and is prompted for a login and password. Secure FTP Secure FTP is an appropriate alternative to the SHP Secure EDI Portal for large volume trading partners. For submitting and retrieving files via Secure FTP, access is available free of charge to trading partners. Secure FTP setup will usually occur during trading partner enrollment. Secure Web Service Secure Web Service is available to trading partners via HTTPS. For submitting and retrieving files via Secure Web Service, access is available free of charge to trading partners. Protocol Family: HTTP Security Health Plan 837 Companion Guide (Institutional) 8 Application Protocol: HTTPS HTTP Language: HTML HTTP Method: POST HTML element for X12 transaction data: payload Passwords Trading Partner ID The Trading Partner ID links the trading partner to their transaction data and is the Security Health Plan s internal key to accessing their trading partner information. Login Credentials In order to receive your authorized user login credentials, all trading partners, regardless of submission method, must be enrolled with Security Health Plan and approved as trading partners. Login credentials include names ids and passwords, that will be required for the submission of transactions to Security Health Plan. A user ID and password will be assigned for the chosen communication method. 5 CONTACT INFORMATION Please have the following information available when calling Security Health Plan s Provider Relations department regarding transmission and production issues: Trading Partner ID and Name Communication Method Login Name for Communication Method Any transactional data needed for specific issues regarding transactions EDI Customer Service The contact information for customer service is as follows: 715-221-9640 shpprd securityhealth.org EDI Technical Assistance In the event of technical difficulties please call 715-221-9640 or email shpprd securityhealth.org Provider Service Number Security Health Plan s Provider Relations department should be contacted 715-221-9640 or shpprd securityhealth.org. Applicable Websites E-Mail CAQH CORE http: www.caqh.org Washington Publishing Company http: www.wpc-edi.com ASC X12 guides: http: store.x12.org store 6 CONTROL SEGMENTS ENVELOPES ISA-IEA This section describes the use of the Interchange Control segments, ISA and IEA. These segments mark the beginning and ending of an interchange. The ISA segment has a fixed length and all the elements within this Security Health Plan 837 Companion Guide (Institutional) 9 segment must be populated. This segment includes a description of the expected sender and receiver codes and delimiters. Segment Element Name Code Definition of Code Notes ISA Interchange Control Header The ISA is a fixed-length record with fixed-length elements. Note: Deviating from the standard ISA element sizes will cause the interchange to be rejected. ISA01 Authorization Information Qualifier 00 No Authorization Information Present ISA02 Authorization Information SHP requires 10 blank spaces ISA03 Security Information Qualifier 00 No Security Information Present ISA04 Security Information SHP requires 10 blank spaces ISA05 Interchange ID Qualifier of Sender ZZ Mutually defined ISA06 Interchange Sender ID Interchange Sender ID is determined during set up by Security Health Plan ISA07 Interchange ID Qualifier of Receiver ZZ Mutually Defined ISA08 Interchange Receiver ID Interchange Receiver ID is determined during set up by Security Health Plan (Common values are SHP, 391572880, 390452970). ISA09 Interchange Date YYMMDD Date of the interchange ISA10 Interchange Time HHMM Time of the interchange ISA11 Repetition Separator This is the delimiter used to separate repeated occurrences of a simple data element or a composite data structure ISA12 Interchange Control Version Number 00501 ISA13 Interchange Control Number Must be identical to IEA02 ISA14 Acknowledgement Requested 0 or 1 0: No acknowledgement requested Security Health Plan 837 Companion Guide (Institutional) 10 1: Acknowledgement requested ISA15 Usage Indicator P or T P: Production Data T: Test Data ISA16 Component Element Separator Component element separator is a delimiter and not a data element IEA Interchange Control Trailer Segment IEA01 Number of Included Functional Groups Functional Group count IEA02 Interchange Control Number Identical to ISA13 GS-GE This section describes Security Health Plan 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 Security Health Plan expects functional groups. These discussions will describe how similar transaction sets will be packaged and Security Health Plan s use of functional group control numbers. Segment Element Name Code Definition of Code Notes GS Functional Group Header GS01 Functional Identifier Code HC Health Care Claim (837) GS02 Application Sender s Code Enter the same value as ISA06, the nine-digit submitter number assigned by Security Health Plan GS03 Application Receiver s Code Receiver s Code is determined during set up by Security Health Plan, and is commonly the same value as ISA08 GS04 Date CCYYMMDD Date of functional group creation GS05 Time HHMM Creation time GS06 Group Control Number Identical to GE02 GS07 Responsible Agency Code X Accredited Standards Committee X12 GS08 Version Release Industry Identifier Code 005010X223A 2 Standards Approved for Publication by ASC X12 Procedures Review Board Security Health Plan 837 Companion Guide (Institutional) 11 through October 2003 GE Functional Group Trailer GE01 Number of Transaction Sets Included Number of transactions included GE02 Group Control Number Identical to GS06 ST-SE This section indicates the beginning and the ending of a transaction set and provides the count of the transmitted segments including the beginning (ST) and ending (SE) segments. These segments also provide a Transaction Set Control Number which must be identical in each segment. Segment Element Name Code Definition of Code Notes ST Transaction Set Header ST01 Transaction Set Identifier 837 Health Care Claim ST02 Transaction Set Control Number Identical to SE02 ST03 Implementation Convention Reference 005010X223A2 This element contains the same value as GS08. SE Transaction Set Trailer SE01 Transaction Segment Count Total number of segments included in a transaction set including ST and SE segments. SE02 Transaction Set Control Number Identical to ST02 Security Health Plan 837 Companion Guide (Institutional) 12 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS Many of the data elements detailed in this Companion Guide reflect Security Health Plan s business requirements, but still meet the standard requirements in the ASC X12N Implementation Guide. Inclusion of a business-required data field, as defined by this Companion Guide, will aid in the delivery of a positive response from Security Health Plan. Note on decimal amount fields: Even though the X12N transaction defines Amount fields as having an 18-byte maximum, there is an additional HIPAA rule that limits all decimal fields to a maximum of 10 characters, including the two implied or reported decimal places. Accordingly, for all decimal or amount fields: 123456789012 is not an acceptable amount, because it is greater than 10 bytes. 12345678.90 is acceptable because the number of digits is not greater than 10; the decimal point itself is not limited by the rule. However, 1234567890 is not acceptable because the X12N engine assumes that a decimal point and succeeding zeroes are implied so that the actual number being communicated is 1234567890.00, which is greater than 10 bytes. The 10-byte limitation applies to all decimal or amount fields, including AMT segments, but also including any other fields that hold amounts or decimals, such as 837 SV207, CAS03, CAS06, CAS09, CAS12, CAS15, CAS18, HI01-5, HI02-5, HCP02 and HCP03, etc. For all fields not listed in these bullets, follow the guidelines in the ASC X12N Implementation Guides (TR3), available at http: store.x12.org store healthcare-5010-consolidated-guides 8 ACKNOWLEDGEMENTS AND OR REPORTS Report Inventory A proprietary version can be provided electronically by request. 9 TRADING PARTNER AGREEMENTS To initiate the evaluation process for potentially becoming a Trading Partner with Security Health Plan, please contact us at 715-221-9640 or shpprd securityhealth.org In your request, please include the following information: Company Name and Address Primary and Alternate Contact Information (Email Address and Phone Numbers) Trading Partners An EDI Trading Partner is defined as any Security Health Plan customer (provider, billing service, software vendor, etc.) that transmits to, or receives electronic data from Security Health Plan. 10 TRANSACTION SPECIFIC INFORMATION This section contains data clarifications, including Security Health Plan-specific data requirements. For additional guidance on the use of business rules, please see Section 7. Loop 1000A Submitter Name Segment Element Industry Name Comments Security Health Plan 837 Companion Guide (Institutional) 13 Submitter Name (NM1) NM1 NM101 Entity identifier code Enter the value 41 for submitter NM108 Identification code qualifier Enter the value 46 for electronic transmitter identification number NM109 Submitter identifier Enter the same value as ISA06, the nine-digit submitter number assigned by Security Health Plan Loop 1000B Receiver Name Segment Element Industry Name Comments Receiver Name (NM1) NM1 NM101 Entity identifier code Enter the value 40 for receiver NM102 Entity type qualifier Enter the value 2 for non-person entity NM103 Receiver name Enter Security Health Plan NM108 Identification code qualifier Enter the value 46 for electronic transmitter identification number NM109 Identification code or receiver primary identifier Enter the same value as GS03, SHP, or 39045 for Security Health Plan Loop 2010 Billing Provider Detail Segment Element Industry Name Comments Billing Provider Name (NM1) 2010AA NM1 Billing Provider name Enter information about the billing provider in this loop. NM108 Identification code qualifier Enter the value XX for National Provider ID NM109 Billing Provider ID National Provider ID for the billing provider REF01 Billing Provider Secondary ID qualifier Enter the value EI for Employer Identification Number REF02 Billing Provider Secondary ID qualifier Enter the Employer Identification Number (tax ID for the billing provider) Loop 2010 Subscriber Detail Segment Element Industry Name Comments Subscriber Name (NM1) 2010BA NM1 Subscriber Name Enter information about the subscriber recipient in this loop NM108 Identification Code Qualifier MI Security Health Plan 837 Companion Guide (Institutional) 14 NM109 Subscriber Identification Code Enter the recipient s 12-digit Subscriber Number. Security Health Plan Member ID. Note: do not enter any other numbers or letters. Use the SHP identification card. Payer Name (NM1) 2010BB NM1 Payer Name Enter information about the payer in this loop NM108 Identification Code Qualifier PI NM109 Payer Identification Code Enter SHP for Security Health Plan s Primary Payer Identification. Other acceptable values are 39045 and 35202 (this value should be used only for Security Administrative Services claims). Patient Detail (NM1) 2010CA NM1 Patient Name Enter information about the patient in this loop (if different from the subscriber) Loop 2300 Claim Information Segment Element Industry Name Comments Claim Information 2300 CLM02 Total claim charge amount Enter the total billed amount for the entire claim CLM05-3 Claim frequency type code Use the claim frequency code to indicate if the claim is being submitted for the first time or if it is a replacement or void of a previously submitted claim. Enter the value 1 to indicate it is the first time a claim is submitted to Security Health Plan. Enter the value 7 to indicate this claim is replacing a previously submitted claim. Enter the value 8 to indicate the previously submitted claim is to be voided. Other Subscriber Information 2320 SBR Other Subscriber Information Include this loop if the claim will be processed by multiple payers CAS Claim level adjustments Include this segment when another payer has made payment at the claim level AMT Coordination of benefits (COB) payer paid amount This segment contains the amount paid on this claim by the payer within this 2320 loop. AMT01 Amount qualifier code Enter the value D for payer amount paid. AMT02 Payer paid amount Enter the amount paid on this claim by the payer Security Health Plan 837 Companion Guide (Institutional) 15 within this 2320 loop 2330B NM1 Other Payer Name This segment contains information on the other payer. NM109 Other payer primary identifier Enter the other payer s identifier Loop 2400 Service Line Segment Element Industry Name Comments Service Line 2400 SV201 Service line revenue code Enter the revenue code for the service performed. SV202 Composite medical procedure identifier Enter a healthcare Common Procedural coding system (HCPCS) code, when necessary to supplement the revenue code SV202-1 Product or service ID qualifier Enter the value HC for Healthcare Common Procedural Coding System (HCPCS) SV202-2 Procedure code Enter the HCPCS CPT code for the procedure performed SV202-3 Procedure modifier 1 Enter a HCPCS CPT modifier code, if necessary to clarify the procedure code. SV202-4 Procedure modifier 2 Enter a HCPCS CPT modifier code, if necessary to clarify the procedure code. SV202-5 Procedure modifier 3 Enter a HCPCS CPT modifier code, if necessary to clarify the procedure code. SV202-6 Procedure modifier 4 Enter a HCPCS CPT modifier code, if necessary to clarify the procedure code. SV203 Line item charge amount Enter the billed amount for the service line SV204 Unit or basis for measurement code Enter the value DA for days or UN for unit SV205 Service unit count Enter the number of minutes or units for the services provided DTP01 Date time qualifier Enter the value 472 for service date(s) DTP02 Date time period format qualifier Enter value D8 to indicate a single date of service or RD8 to indicate a range of service dates DTP03 Service date Enter the date(s) the procedure was performed 2430 SVD01 Other payer primary identifier Enter the other payer s primary identifier if another payer has paid on the service line SVD02 Service line paid amount Enter the amount the other payer paid on the service line Security Health Plan 837 Companion Guide (Institutional) 16 CAS Line adjudication information Include this segment when another payer has made payment at the service line. APPENDICES Implementation Checklist Security Health Plan does not offer an Implementation Checklist for our Trading Partner EDI services. Security Health Plan assists new Trading Partners with enrollment and testing, but a formal implementation checklist is not necessary. Business Scenarios Please contact the Security Health Plan Provider Relations Department to discuss your specific EDI related business needs with Security Health Plan, should they not be covered in this guide or other available Security Health Plan transaction companion guides. Transmission Examples Please contact the Security Health Plan Provider Relations Department for any question regarding transmission examples. Frequently Asked Questions N A Change Summary Date Section(s) Changed Change Summary June 2016 Initial version with the CORE template. April 2020 1,6,10 Updated hyperlinks, valid values, and descriptions. November 2022 2,3,4,5,9 Updated hyperlinks, email addresses, communication protocol descriptions, and process flow diagram. | /kaggle/input/edi-db-835-837/837-Institutional-Companion-Guide.pdf | 99fec9f334dea8059cbebc80e0c25033 | 99fec9f334dea8059cbebc80e0c25033_0 |
NYEIS New York State Department of Health Center for Community Health Bureau of Early Intervention 837 Health Care Claim Professional Companion Guide HIPAA 005010X222A1 837: Health Care Claim: Professional Version: 1.13 Published: 6 14 2016 The New York State Department of Health retains title and copyright of this Companion Guide. The Companion Guide must not be published. 2010 NYS Department of Health Copyright New York State Department of Health ii This page intentionally left blank Version Control Version 1.0 Original Published 04 07 2010 Version 1.1 Published 07 14 2010 Reference to the data element SV505 on page 10 was removed. Reference to the instruction for Loop 2300 The sum of all service lines enhanced with the addition of for this claim. Version 1.2 Published 09 07 2010. Reference to the data element REF02 for Loop 2300 was modified to require capability to accept a maximum field width of up to 30. Reference to the data element HI01 2 for Loop 2300 was included to specify that decimal points in ICD-9 codes are assumed. ICD-9 codes should be transmitted without the decimal points. Version 1.3 Published 10 12 2010 Reference to the data element CLM09 for Loop 2300 was modified to read Must use Y. Reference to the data element CLM10 for Loop 2300 was modified to read Must use B. Version 1.4 Published 12 20 2010 Reference to the data element ST02 was removed. Reference to the data element BHT03 was added. Version 1.5 Published 11 10 2011 Moved Version Control to Page 1 Companion Guide Contact Information changed from Center for Community Health s Office of Information Technology and Project Management to Public Health Informatics and Project Management Office at 518-473-4959 Updated Table of Contents page numbers Added comment for Data Element ISA13 of the Interchange Control Header This value must be unique for each submission from a provider Updated Data Element Name for NM103 (Loop 1000B) to read Name Last or Organization Name Corrected Data Element Name for NM108 (Loop 2010BA) to read Identification Code Qualifier Removed Claim Frequency Type Code from the Comments section for CLM-05 (Loop 2300) Added Data Element DTP02 Date Time Period Format Qualifier (Lop 2300): Use D8 CCYYMMDD Added Data Element DTP03 Date Time Period (Loop 2300): Enter one claim date. Added comment to NM108 (Loop 2310B) to read If the National Provider Identifier (NPI) for the rendering provider is available and is being reported in NM109 of this loop, then enter XX. If the provider s NPI is not available and the Employer Identification Number (EIN) for the rendering provider is being reported in NM109 of this loop, then enter 24. If neither the NPI nor the EIN is available and the Social Security Number (SSN) for the rendering provider is being reported in NM109 of this loop, then enter 34. Changed comment for DTP03 (Loop 2400) to read Enter one service date. This date must be the same for all service lines included in the claim (Loop 2300). Added comment for NTE02 (Loop 2400): Do not use special characters (i.e.: ). and All service coordination provided on the same day must be reported on one claim and each encounter of service coordination for that day must be reported on separate service lines Added Appendix B Provider Electronic Claiming Summary Version 1.6 Published 02 17 2012 Added note under General Information defining segment terminators and data delimiters. Deleted Transmission Type Identification (REF) Loop, Added note for NTE02 in Loop 2300. For Evaluations this data element is not required. Deleted Codes 24 and 34 for NM108 in Loop 2310B. NM109 is limited to NPI number in Loop 2310B. Added REF01 and REF02 to 2310B along with notes on how to use the new REF segment in the 2310B Loop to hold a rendering providers State ID or NYEIS employee reference. Service Facility Location has changed from Loop 2310D to Loop 2310C Deleted Code FA for NM101 in loop 2310C Service Provider Name has changed from Loop 2310E to Loop 2310D Added REF01 and REF02 to 2310D along with notes on how to use the new REF segment in the 2310D Loop to hold a rendering providers State ID or NYEIS employee reference. Change date format from CCYYMMDD to YYYYMMDD iii Version 1.7 Published 04 02 2012 General Information, second bullet changed to read NYEIS will only accept one Functional Group Header Functional Group Trailer (GS GE) envelope. General Information, third bullet changed to read NYEIS will only accept one Transaction Set Header Transaction Set Trailer (ST SE). ISA16 Component Element Separator was changed to read Use: Note on using the Segment Terminator following ISA16 was added and reads Use " ". Insert a Tilde immediately following ISA16. 2310B Loop: Replaced the rendering providers State ID or NYEIS employee reference number as the Secondary Identifier with the Employer Identification Number (EIN) or Social Security Number (SSN). Receive 835 Remittance - Pg 21, 3rd paragraph. Changed the 835 file naming convention to read: The 835 naming convention will be 835, followed by the amount of the 835, followed by the date associated with the 835, followed by the Control Number of the 835. An example of a new filename follows the above wording. Replaced Tips for Reading the 997 Functional Acknowledgement File in Appendix B with Tips for Reading the 999 Functional Acknowledgement File. Version 1.8 Published 04 27 2012 2000C Loop: Added Loop with note indicating that a Patient Hierarchical Level (Loop 2000C) should not be included in the file because the child patient is identified in 2010BA NM109. 2300 Loop: Removed DTP02 and DTP03 from the Claim Information (Loop 2300). 2310B Loop: Added the following wording at the top of the 2310B Loop: The actual rendering provider must be reported at the claim level (2310B loop) and not at the service line level (2420A loop). 2310B Loop: Changed wording from If the rendering provider s NPI is not available leave NM108 and NM109 blank to If the rendering provider s NPI is not available do not send NM108 and NM109. 2310D Loop: Replaced the supervising provider s State ID or NYEIS employee reference number as the Secondary Identifier with the Employer Identification Number (EIN) or Social Security Number (SSN). 2310D Loop: Removed wording The supervising provider s State ID or NYEIS employee reference number entered here will be checked against the rendering provider's identifier in NYEIS. If the identifier does not match, the claim will be denied with "This provider does not exist on NYEIS". Version 1.9 Published 06 29 2012 Removed Secondary Identifiers (SSN or EIN) as an option for providers. 2010AA Loop: NM108 - Must use XX. 2010AA Loop: NM109 - Enter the National Provider Identifier (NPI) of the Billing Provider. 2310B Loop: Removed references to REF01 and REF02 segments. 2310B Loop: NM108 Must use XX. 2310B Loop: NM109 - Enter the National Provider Identifier (NPI) of the Rendering Provider. 2310D Loop: NM108 Must use XX. 2310D Loop: NM109 - Enter the National Provider Identifier (NPI) of the Supervising Provider. Version 1.10 Published 09 27 2013 General Service claims, Assistive Technology Device (ATD) claims and Respite claims must be submitted in separate 837P files. Version 1.11 Published 7 20 2015 2310A Loop: OPRA Referring Provider requirement added 2310A Loop: NM101 - Must enter "DN" Referring Provider, for first iteration of this loop 2310A Loop: NM102 - Must enter "1" Person 2310A Loop: NM103 - Must enter the last name or organization name 2310A Loop: NM108 - Must use XX. 2310A Loop: NM109 - Must enter the National Provider Identifier (NPI) of the Billing Provider. iv Version 1.12 Published 9 04 2015 ICD-10 diagnosis codes are now accepted by NYEIS. 2300 Loop: Added data element HI01 - 01 to identify the proper code list qualifier to use for submitting ICD-10 diagnosis codes versus ICD-9 diagnosis codes. Added segments HI02, HI03, and HI04. Included text to note how many diagnosis codes are supported by NYEIS. Updated the text of F-File errors related to ICD codes to remove ICD9-specfic text and make them generic for all versions of ICD codes. Version 1.13 Published 6 14 2016 Minor updates i Table of Contents Table of Contents................................................................................................................................................... i Introduction........................................................................................................................................................... 1 General Information........................................................................................................................................... 1 Enrollment......................................................................................................................................................... 1 Segments.............................................................................................................................................................. 3 Interchange Control Header (ISA)..................................................................................................................... 3 Functional Group Header.................................................................................................................................. 4 Transaction Set Header (ST)............................................................................................................................ 4 Beginning of Hierarchical Transaction (BHT).................................................................................................... 5 Submitter Name Loop 1000A............................................................................................................................ 5 Receiver Name (Loop 1000B)........................................................................................................................... 6 Billing Provider Name (Loop 2010A)................................................................................................................. 6 Subscriber Hierarchical Level (Loop 2000B)..................................................................................................... 6 Subscriber Name (Loop 2010B)........................................................................................................................ 7 Payer Name (Loop 2010BB)............................................................................................................................. 7 Patient Hierarchical Level (Loop 2000C)........................................................................................................... 7 Claim Information (Loop 2300).......................................................................................................................... 8 Referring Provider Name (Loop 2310A).......................................................................................................... 11 Rendering Provider Name (Loop 2310B)........................................................................................................ 12 Service Facility Location (Loop 2310C)........................................................................................................... 12 Supervising Provider Name (Loop 2310D)...................................................................................................... 13 Other Subscriber Information (Loop 2320)...................................................................................................... 13 Service Line (Loop 2400)................................................................................................................................ 14 Appendix A.......................................................................................................................................................... 15 County Codes.................................................................................................................................................. 15 Appendix B.......................................................................................................................................................... 17 Upload the 837P Claim File to NYEIS............................................................................................................. 17 Check the Status of the Uploaded 837P Claim File by Reviewing the Response File(s)............................... 17 Step One The 999 Functional Acknowledgement Response...................................................................... 17 Step Two The F-File Response.................................................................................................................... 18 How to Access the Response Files................................................................................................................. 18 ii Adjudicate the Claim........................................................................................................................................ 20 Receive 835 Remittance................................................................................................................................. 20 Tips for Reading the 999 Implementation Acknowledgement File.................................................................. 21 999 Legend for the IK3 and IK4 segments...................................................................................................... 22 Tips for Reading the F-File Response File...................................................................................................... 25 F-File Error Guidance...................................................................................................................................... 26 Check for Early Intervention Claiming Errors.................................................................................................. 43 1 Introduction The attached 837 Professional Companion Guide provides the specifics for submitting provider Early Intervention service claims to the New York Early Intervention System (NYEIS). The Companion Guide must be used in conjunction with Washington Publishing Company s Combined 005010X222 005010X222A1 837 Health Care Claim: Professional. This document may be found at: http: www.wpc-edi.com General Information NYEIS will only accept one Interchange Control Header Interchange Control Trailer (ISA IEA) envelope. NYEIS will only accept one Functional Group Header Functional Group Trailer (GS GE) envelope. NYEIS will only accept one Transaction Set Header Transaction Set Trailer (ST SE) envelope. No more than 5,000 claims can be submitted within the ST SE envelope. Currently NYEIS is only supporting the 837 Professional transaction set. NYEIS is not currently supporting electronic adjustments or replacements to previously submitted claims. Transportation and respite services are not supported in the 837 Professional transaction set. Record time in 24-hour clock time as follows: HHMM, where HH hours (00-23) and MM minutes (00- 59). Delimiters to be used in the EDI file: 1) Segment Terminator, use a tilde 2) Data Element Delimiter, use an asterisk 3) Repetition Separator, use a carat 4) Component Element Delimiter, use a colon: EDI files should not contain any cr lf characters. The EDI file name should not contain any special characters. Only letters, numbers and underscores should be used. Periods should only be used once, right before the file extension (e.g. Filename.edi). Enrollment To enroll for submitting your claims electronically, logon to the Health Commerce System (HCS): Select the My Content button on the Top Menu Bar of the HCS Portal page, and then select Documents by Group. Click on the link for your appropriate group from the My Groups section (e.g., LHD, Health Care) o If you do not see your Group in the drop down, click the View All Document Groups link. Select the green next to your group. Select the "Family and Community Health" link from the Document Groups section Select the "Early Intervention" link from the Document Groups section Select the "NYEIS" link from the Document Groups section. o Click on Add to Fav at the end of this displayed path to more easily access the NYEIS Document Group from HCS Home. Select the Provider Electronic Claiming folder 2 Download the Procedures to Request Electronic Claiming and the Request to Submit Electronic Claims documents and follow the instructions. If you have questions, please e-mail NYEIS health.ny.gov. 3 Segments Interchange Control Header (ISA) Interchange Control Header (ISA) Data Element Data Element Name Comments ISA01 Author Information Qualifier Must use "00". ISA03 Security Information Qualifier Must use "00". ISA05 Interchange ID Qualifier Must use "ZZ". ISA06 Interchange Sender ID Provider or Clearinghouse Electronic Transmitter Identification Number (ETIN), defined in Trading Partner Agreement. ISA07 Interchange ID Qualifier Must use "ZZ". ISA08 Interchange Receiver ID Must use "NYEIS". ISA09 Interchange Date Format: YYMMDD. ISA10 Interchange Time Format: HHMM. ISA11 Repetition Separator Must use " ". ISA12 Interchange Control Version Number Must use 00501. ISA13 Interchange Control Number Must be identical to IEA02. This value must be unique for each transmission from a provider. ISA15 Usage Indicator Use "T" for Test or "P" for Production. ISA16 Component Element Separator Use ":". Segment Terminator Use " ". Insert a Tilde immediately following ISA16. 4 Functional Group Header Functional Group Header (GS) Data Element Data Element Name Comments GS01 Functional Identifier Code Must use "HC". GS02 Application Sender's Code Provider or Clearinghouse (ETIN), defined in Trading Partner Agreement. GS03 Application Receiver's Code Must use "NYEIS". GS04 Date Format: YYYYMMDD. GS05 Time Format: HHMM. GS06 Group Control Number Must be identical to GE02. GS08 Version Release Industry Identifier Code Must use 005010X222A1. Transaction Set Header (ST) Transaction Set Header (ST) Create a separate ST-SE loop for each Municipality being submitted Data Element Data Element Name Comments ST01 Transaction Set Identifier Code Must use "837". 5 Beginning of Hierarchical Transaction (BHT) Beginning of Hierarchical Transaction (BHT) Data Element Data Element Name Comments BHT03 Reference Identification Enter the invoice number for this ST-SE envelope. If Loop 2010AB is present, the invoice number must be unique from all previous invoice numbers submitted for the provider identified in Loop 2010AB including previous invoice numbers submitted using 837's, or entered directly into NYEIS or KIDS. If Loop 2010AB is NOT present, the invoice number must be unique from all previous invoice numbers submitted for the provider identified in Loop 2010AA including previous invoice numbers submitted using 837's, or entered directly into NYEIS or KIDS. BHT06 Transaction Type Code NYEIS will only accept "CH". Submitter Name Loop 1000A Submitter Name (Loop 1000A) Data Element Data Element Name Comments NM109 Identification Code Your Electronic Transmitter Identification Number (ETIN), established by Trading Partner agreement with NYEIS, must be entered here. PER03 Communication Number Qualifier Use "EM", "FX", or "TE". 6 Receiver Name (Loop 1000B) Receiver Name (Loop 1000B) Data Element Data Element Name Comments NM103 Name Last or Organization Name Must use Municipality's name "- Early Intervention"; see Appendix A. NM109 Identification Code The Municipality's County Code is entered here; see Appendix A. Billing Provider Name (Loop 2010AA) Billing Provider Name (Loop 2010AA) Data Element Data Element Name Comments NM108 Identification Code Qualifier Must use "XX". NM109 Identification Code Enter the National Provider Identifier (NPI) of the Billing Provider. The billing provider NPI entered here will be checked against the billing provider's NPI in NYEIS. If the NPI does not match, an F-File error will be generated for the file. Subscriber Hierarchical Level (Loop 2000B) Subscriber Hierarchical Level (Loop 2000B) Data Element Data Element Name Comments SBR01 Payer Responsibility Sequence Number Code Must use "P". SBR02 Individual Relationship Code Must use "18". 7 Subscriber Name (Loop 2010B) Subscriber Name (Loop 2010BA) For children with Medicaid Assistive Technology Device (ATD) claims, use Loop 2320. Data Element Data Element Name Comments NM102 Entity Type Qualifier Must use "1" for Person. NM108 Identification Code Qualifier Must use "MI". NM109 Identification Code Must use Child's NYEIS Reference Number. Payer Name (Loop 2010BB) Payer Name (Loop 2010BB) Data Element Data Element Name Comments NM108 Identification Code Qualifier Must use "PI". NM109 Identification Code The Municipality's County Code is entered here; see Appendix A. Patient Hierarchical Level (Loop 2000C) Patient Hierarchical Level (Loop 2000C) Do not include a Patient Hierarchical Level (Loop 2000C) in your files since the child patient is identified in the 2010BA NM109 data element of the Subscriber Hierarchical Level. Subscriber information should be included in the Subscriber Hierarchical Level (Loop 2000B). Your claims will not be processed if the Subscriber information is not in the Subscriber Hierarchical Level. 8 Claim Information (Loop 2300) Claim Information (Loop 2300) Data Element Data Element Name Comments CLM01 Claim Submitter's Identifier The claim number must be unique from all previous claim numbers submitted for the provider of record, including previous claim numbers submitted using 837's, or entered directly into NYEIS or KIDS. CLM05-1 Facility Code Value Must use one of the following values: 11 Office 12 Home 21 Inpatient Hospital 22 Outpatient Hospital 31 Skilled Nursing Facility 99 Other Unlisted Facility CLM05-3 Claim Frequency Type Code Must use 1 Original or 8 Void. NYEIS is not currently supporting electronic adjustments or replacements to previously submitted claims. CLM08 Yes No Condition or Response Code (Assignment of Benefits) Must be "N". CLM09 Release of Information Code Must use "Y". CLM10 Patient Signature Source Code (This is a required element) Must use "P". REF01 Reference Identification Qualifier Must use "G1". REF02 Reference Identification Must report NYEIS Service Authorization Number. Provider s system must be able to accept a maximum field width of up to 30. NTE01 Note Reference Code Must use "ADD". 9 Claim Information (Loop 2300 Continued) NTE02 Description For General Services report the visit type, the visit begin time and the visit end time. Visit types are: "CV1" Regular Visit, "CV2" Make-up Visit, "CV3" Co-Visit. Format: Visit Type-HHMM-HHMM. Do not use special characters (i.e.: ). For Service Coordination, use Loop 2400 NTE02. For Evaluations this data element is not required. HI01 Health Care Code Info. A diagnosis must be included on a claim HI01 - 01 Code List Qualifier Code Use ABK if HI01 - 02 is an ICD-10 diagnosis code. Use BK if HI01 - 02 is an ICD-9 diagnosis code. HI01 - 02 Industry Code Submit a diagnosis code in this data element. Do not transmit the decimal point in the diagnosis code. The decimal point is assumed. HI02 Health Care Code Info. An additional diagnosis code can be included on a claim HI02 - 01 Code List Qualifier Code Use ABF if HI02 - 02 is an ICD-10 diagnosis code. Use BF if HI02 - 02 is an ICD-9 diagnosis code. HI02 - 02 Industry Code Submit a diagnosis code in this data element. Do not transmit the decimal point in the diagnosis code. The decimal point is assumed. HI03 Health Care Code Info. An additional diagnosis code can be included on a claim 10 Claim Information (Loop 2300 Continued) HI03 - 01 Code List Qualifier Code Use ABF if HI03 - 02 is an ICD-10 diagnosis code. Use BF if HI03 - 02 is an ICD-9 diagnosis code. HI03 - 02 Industry Code Submit a diagnosis code in this data element. Do not transmit the decimal point in the diagnosis code. The decimal point is assumed. HI04 Health Care Code Info. An additional diagnosis code can be included on a claim HI04 - 01 Code List Qualifier Code Use ABF if HI04 - 02 is an ICD-10 diagnosis code. Use BF if HI04 - 02 is an ICD-9 diagnosis code. HI04 - 02 Industry Code Submit a diagnosis code in this data element. Do not transmit the decimal point in the diagnosis code. The decimal point is assumed. HI05 thru HI12 Health Care Code Info. Additional Diagnosis codes can be submitted but are not processed by NYEIS Use ICD 9 diagnosis codes for claims with date of service on or before 9 30 2015 Use ICD 10 diagnosis codes for claims with date of service on or after 10 1 2015 11 Referring Provider Name (Loop 2310A) Referring Provider Name (Loop 2310A) This loop is required for all non-vendor based claims. Non-vendor based claims include General Service, Service Coordination, and Evaluation claims. The actual referring provider must be reported at the claim level (2310A loop) and not at the service line level (2420F loop). Data Element Data Element Name Comments NM101 Entity ID Code Must enter "DN" Referring Provider NM102 Entity Type Qualifier Must enter "1" Person NM103 Name Last Org Name Must enter the last name or organizational name of the referring provider NM108 Identification Code Qualifier Must use XX NM109 Identification Code Must enter the National Provider Identifier (NPI) of the referring provider. The referring provider NPI entered here will have the following pre-adjudication edit checks run against it: The referring provider NPI must be submitted with the claim The length of the NPI must be ten. The NPI must be numeric The NPI must pass a checksum validation that is based on an established formula for NPIs Any failed edit checks will result in the generation of an F-File error for the claim. See the related referring provider F-File error messages in the Check for Early Intervention Claiming Errors section of Appendix B. 12 Rendering Provider Name (Loop 2310B) Rendering Provider Name (Loop 2310B) The actual rendering provider must be reported at the claim level (2310B loop) and not at the service line level (2420A loop). Data Element Data Element Name Comments NM102 Entity Type Qualifier Must enter "1" Person. NM108 Identification Code Qualifier Must use "XX". NM109 Identification Code Enter the National Provider Identifier (NPI) of the Rendering Provider. The rendering provider NPI entered here will be checked against the rendering provider's NPI in NYEIS. If the NPI does not match, the claim will be denied with "This provider does not exist on NYEIS". Service Facility Location (Loop 2310C) Service Facility Location (Loop 2310C) Required when the place of service is different than reported in Billing Provider 2010AA or Pay-to Provider 2010AB. If the service was rendered in patient s home do not report this loop; report the place of service in CLM05-1. Data Element Data Element Name Comments NM101 Identification Code Qualifier Must use "77" NM103 Name Last or Organization Name Required except when service was rendered in the patient's home. 13 Supervising Provider Name (Loop 2310D) Supervising Provider Name (Loop 2310D) Required when the rendering provider requires supervision by a licensed professional. Data Element Data Element Name Comments NM108 Identification Code Qualifier Must use "XX". NM109 Identification Code Enter the National Provider Identifier (NPI) of the Supervising Provider. The supervising provider NPI entered here will be checked against the supervising provider's NPI in NYEIS. If the NPI does not match, the claim will be denied with "This provider does not exist on NYEIS". Other Subscriber Information (Loop 2320) Other Subscriber Information (Loop 2320) This loop is only required for reporting the results of Assistive Technology Device (ATD) claiming for children with commercial insurance and Medicaid or with Medicaid only. If the child has commercial insurance and Medicaid, report the results of the commercial insurance claiming in this loop. Report the results of the commercial insurance claiming even if the amount paid is zero. Report the results of the Medicaid claiming in this loop even if the amount paid is zero. Note: For children with Commercial Insurance and no Medicaid, do not report this loop. Data Element Data Element Name Comments SBR01 Payer Responsibility Sequence Number Code When the child has commercial insurance and Medicaid, report "P" in the commercial insurance loop and "S" in the Medicaid loop. When the child has Medicaid only, report "P" in the Medicaid loop. SBR02 Individual Relationship Code Report an appropriate code in the commercial insurance loop. Report "18" in the Medicaid loop. CAS01 Claim Adjustment Group Code NYEIS expects to receive "CO" only. AMT02 Monetary Amount Paid amount of zero is acceptable. OI03 Yes No Condition or Response Code Must be "N". 14 Service Line (Loop 2400) Service Line (Loop 2400) The sum of all service lines for this claim must add up to the Monetary Amount in CLM02, Loop 2300 Data Element Data Element Name Comments SV101-1 Product Service ID Qualifier Service ID Qualifier; enter "HC". SV103 Unit or Basis for Measurement Code Enter "UN" Unit. DTP01 Date Time Qualifier Use "472". DTP02 Date time period format qualifier Use "D8" YYYYMMDD. DTP03 Date time period Enter one service date. This date must be the same for all service lines included in the claim (Loop 2300). NTE01 Note Reference Code Required only for Service Coordination claims. Must use "ADD". NTE02 Description For Service Coordination, record the begin time and end time for each encounter. Format is: HHMM-HHMM. Do not use special characters (i.e.: ). All service coordination provided on the same day must be reported on one claim and each encounter of service coordination for that day must be reported on separate service line(s). When an encounter is on a different day, then a new 2300 claim information loop must be reported. 15 Appendix A County Codes Municipality County Code Albany 01 Allegany 02 Broome 03 Cattaraugus 04 Cayuga 05 Chautauqua 06 Chemung 07 Chenango 08 Clinton 09 Columbia 10 Cortland 11 Delaware 12 Dutchess 13 Erie 14 Essex 15 Franklin 16 Fulton 17 Genesee 18 Greene 19 Hamilton 20 Herkimer 21 Jefferson 22 Lewis 24 Livingston 25 Madison 26 Monroe 27 Montgomery 28 Nassau 29 Niagara 31 NY City 70 Oneida 32 Onondaga 33 Ontario 34 Orange 35 Orleans 36 Oswego 37 Otsego 38 Putnam 39 Rensselaer 41 Rockland 43 St. Lawrence 44 Saratoga 45 Schenectady 46 Schoharie 47 16 Schuyler 48 Seneca 49 Steuben 50 Suffolk 51 Sullivan 52 Tioga 53 Tompkins 54 Ulster 55 Warren 56 Washington 57 Wayne 58 Westchester 59 Wyoming 60 Yates 61 17 Appendix B Provider Electronic Claiming Summary The following steps summarize the general flow of events that occur when a provider submits an electronic claim file (837P) to NYEIS. Upload the 837P Claim File to NYEIS Electronic claim files that adhere to the HIPAA 5010A EDI transaction format can be uploaded to NYEIS for processing. 1. To submit an 837P claim file to NYEIS, select the Upload 837 Invoice menu option. 2. A screen will display allowing you to browse your computer to find the 837P HIPAA claim file. Once selected, click the Save button to upload the file to NYEIS. 3. A confirmation message stating that you have successfully uploaded your file 837P file will be displayed. Important - Once a file has been uploaded to NYEIS it can take up to 24 hours for the file to be processed. In general, check for the first response file from NYEIS the next business day after uploading an 837P file. Check the Status of the Uploaded 837P Claim File by Reviewing the Response File(s) NYEIS processes the receipt of electronic claim file submissions in two steps. Each claim file is first checked to ensure it is a valid HIPAA 5010A file (Step One) and then proprietary pre-adjudication edits are run against the claim file (Step Two). Errors may be generated at each step. This section of the document describes each of these two steps and then provides instructions for how to access and review the related response files generated by NYEIS. Step One The 999 Functional Acknowledgement Response Step one of this process results in the creation of a standard HIPAA 999 Functional Acknowledgement file. This file is used as the first response to a provider after NYEIS receives an 837P claim file from that provider. The purpose of the 999 file is to acknowledge receipt of the 837P file and provide a status pertaining to each segment in the 837P EDI transaction. Tips for reading the 999 file are provided in a separate section near the end of this document. Important - Any errors generated during this step must be corrected and the 837P file must be resubmitted. 18 Step Two The F-File Response Once there are no errors being generated on the 999 file, the submitted 837P is reviewed by step two of the file receipt process. Generally this step occurs within 24 hours after generating an error-free 999 response file. During this step, various pre-adjudication edit checks are performed against the data in the submitted 837P file and an F-File is generated to notify providers of any errors. For example, the ETIN provided in the submitted file is checked for validity. The F-File is structured as a comma-delimited file that can be opened in any text editor or Microsoft Excel for review. Textual error messages are listed in the file (e.g. Submitter ETIN Invalid ) along with additional information to describe the errors. Tips for reading the F-File are provided at the end of this document. Important - If no errors are generated during Step 2, then no F-File response will be generated. If errors are generated, then the user will need to correct the error in their file and resubmit. If the error is at the claim level, such as an invalid Service Authorization number, then only the claims affected need to be submitted on a new 837. If the error is at the header level, such as invalid ETIN, then the entire file typically needs to be resubmitted. The last section of this document explains each of the 837P pre-edits that may result in errors being displayed on the F-File and notes what actions are taken if an edit exception is encountered. How to Access the Response Files 1. To access and review the response file(s) generated by NYEIS and check on the status of a submitted claim file, click on the Download Response Files link from your homepage. 2. The Download HIPAA Transaction Responses list page is displayed (see the screenshot that follows). This page lists the response transaction and also indicates the date the response was created and how many transactions in the 837P file were accepted or rejected based on the standard HIPAA file formatting rules. Please note that the Accepted Rejected Transactions columns are not intended to provide statistics on how many claims in your file have been accepted or rejected. They only indicate whether the transaction sets in your file adhere to standard HIPAA formatting guidelines. You must review the response file(s) to obtain information related to any rejected claims. The Control Number column on this page represents segment ISA13 from the submitted 837P file. The file name in the Response File column is the same as the name of the 837P file that was submitted. To view the responses of a transmission, click on the View action link. 19 After clicking on the View action link, the following screen will appear to allow you to select a file to view by clicking on its name. Remember, the F File Details will only be available if there were errors generated during Step Two of the response process. If there were no errors during this step, then the file will not available for you to select from the screen. 20 Adjudicate the Claim After an 837P passes the 999 and the pre-adjudication edits, then NYEIS runs the rest of the invoice billing rules against the claims. The claims can be approved, denied, or pended similar to online NYEIS Invoicing. The status of the invoice and its claims can now be viewed by searching for the invoice (user selects Invoice under the search section of their user homepage). Every Invoice has an assigned status. Depending on where an Invoice is in the process, will determine the Status. Prior to being submitted, an Invoice is considered Draft, after submission it is considered Submitted and continues through the process. Once the System approves and or denies all Claims, the Invoice is considered Fully Adjudicated, meaning a decision has been made on each Claim. An Invoice will be Partially Adjudicated if any Claim is pended awaiting a waiver decision. Invoices that are voided are given a Void status. Receive 835 Remittance The status of a claim is available on a standard HIPAA 835 Claim Payment Advice file that will be generated by NYEIS and made available to the provider. NYEIS generates 835 s on a daily basis. These 835 files can be accessed via use of the same Download Response Files menu option as used to access the other response files received from NYEIS and described in a previous section of this document. A sample of the Download HIPAA Transaction Responses page is presented below. The 835 naming convention will be 835, followed by the amount of the 835, followed by the date associated with the 835, followed by the Control Number of the 835. A new file name might look like 835_1240_20120107_283924.x12 where 1240 is the amount from the file (BPR02), 20120107 is the date from the file (BPR16), and 283924 is the Control number from the file (ISA13). The amount in the file name will be the same as the reconciled payment amount on the Provider s Provider Financials screen. This makes it easier for providers to visually associate an 835 to a reconciled payment. Click on the View action to go to the File Details page where you can open the file and review it. The following information provides a general guideline for when providers should expect to receive an 835 file from the NYEIS adjudication process: 1. Denied claim If a claim is denied during the adjudication process, an 835 file will be generated and made available to the provider. 2. Approved claim The 835 will be created for an approved claim once the claim has been generated for payment and included on a check or EFT by County Finance Office. Each municipality is responsible for processing their own payments, so the response time for receiving these 835 files will vary. 3. Pended claims The 835 does not support pended claims. Users will receive tasks in their Provider Financial work queue requesting them to provide a billing justification reason for the pended claim. 21 Tips for Reading the 999 Implementation Acknowledgement File An understanding of how to read the standard HIPAA 999 Implementation Acknowledgement file is required in order to comprehend the status of a submitted claim batch and to correct any errors noted at this step in the process. Here are some tips for reading the 999 file: Review the AK9 segment in the 999. If you see an A in the AK9 segment, your file was received and accepted for further processing by NYEIS. Remember: A Accepted. Below is an example of an accepted 999. ISA 00 00 ZZ NYEIS ZZ ALBAnnnn 101210 1032 U 00401 000000201 0 T: GS FA NYEIS ALBAnnnn 20101210 1032 201 X 005010X231A1 ST 999 0001 005010X231A1 AK1 HC 201 005010X222A1 AK9 A 1 1 1 SE 6 0001 GE 1 201 IEA 1 000000201 If you see an R in the IK5 or AK9 segments, your file was rejected. Remember: R Rejected. Below is an example of a rejected 999. To help interpret this example, the superscript numbers provided cross reference the Number column in the 999 legend that is provided below. ISA 00 00 ZZ NYEIS ZZ ALBAnnnn 101210 1032 U 00401 000000201 0 T: GS FA NYEIS ALBAnnnn 20101210 1032 201 X 005010X231A1 ST 999 0001 005010X231A1 AK1 HC 201 005010X222A1 AK2 837 0001 005010X222A1 IK31 NM12 1033 2330B4 85 IK46 097 6710 211 IK5 R AK9 R 1 1 0 SE 6 0001 GE 1 201 IEA 1 000000201 Any time there are IK3 and IK4 segments in a 999, there is a rejected 837P. These segments will appear between the AK2 and IK5 segments (see the previous bullet for an example). The IK3 segment is used to report errors in a data segment in the submitted 837P and identify the location of the data segment in the file. The IK4 segment is used to report errors in a data element or composite data structure in the submitted 837P and identify the location of the data element in the file. See below for the 999 legend that describes each element in the IK3 and IK4 segments. 22 999 Legend for the IK3 and IK4 segments Number Element Name Instructions 1 IK3 Error Identification: This segment is used to report errors in a data segment and identify the location of the data segment. 2 IK301 Segment ID Code This contains the identification of the data segment in error (e.g., NM1 or SV1 ). 3 IK302 Segment Position In Transaction Set This is the numerical count of this data segment from the start of the transaction set (i.e. from the start of the ST loop in the 837P file that was submitted to NYEIS). 4 IK303 Loop Identifier Code This identifies the loop within which the error occurred on the file submitted to NYEIS. 5 IK304 Implementation Segment Syntax Error Code This element contains the error noted for the segment. The codes and descriptions are: 1. Unrecognized segment ID 2. Unexpected segment 3. Required segment missing 4. Loop occurs over maximum times 5. Segment exceeds maximum use 6. Segment not in defined transaction set 7. Segment not in proper sequence 8. Segment has data element errors I4. Implementation Not Used segment present I6. Implementation dependent segment missing I7. Implementation loop occurs under minimum times I8. Implementation segment below minimum use I9. Implementation dependent Not Used segment present CTX Segment Context and Business Unit Identifier: This segment is used to report when the error identified in this IK3 loop was triggered by a situational requirement of the Implementation Guide and the error occurs at the segment level. CTX01-1 Context Name Always contains the value SITUATIONAL TRIGGER. CTX01-02 Context Reference Context Reference CTX02 Segment ID Code Code defining the segment ID of the data segment in error. CTX03 Segment Position in Transaction Set This is the numerical count of this data segment from the start of the transaction set (i.e. from the start of the ST loop in the 837P file that was submitted to NYEIS). The transaction set header (i.e. the ST segment) is count position 1. CTX04 Loop Identifier Code This identifies the loop within which the error occurred on the file submitted to NYEIS. CTX05-01 Element Position in Segment This is used to indicate the relative position of a simple data element, or the relative position of a composite data structure with the relative position of the component within the composite data structure, in error. CTX05-02 Component Data Element Position in Composite Required when the situational requirement relates to a component data element within a composite data structure. CTX05-03 Repeating Data Element in Position Required when the situational requirement relates to a repeating data element. 23 CTX06 Reference in Segment Required when CTX05 is used and the data element reference number of the data element identified in CTX05-1 is known by the submitter of the 999, and it is not a composite data element. CTX06-1 Data Element Reference Number Reference number used to locate the data element in the Data Element Dictionary. CTX06-02 Data Element Reference Number Required when CTX05-2 is used and the data element reference number of the data element identified in CTX05-2 is known. 6 IK4 Implementation Data Element Note: This segment is used to report errors in a data element or composite data structure and identify the location of the data element. 7 IK401-1 Element Position in Segment This is used to indicate the relative position of the data element or composite data structure in error. If CLM03 was in error, the value would be 3. 8 IK401-2 Component Data Element Position in Composite This identifies the component data element position within the composite data structure. This element is only included when an error occurs in a composite data element and the composite data element position can be determined. 9 IK401-3 Repeating Data Element Position This identifies the specific repetition of a data element that is in error. This is a situational element that is not always provided. 10 IK402 Data Element Reference Number This identifies the Data Element Number reference number from the Implementation Guide. 11 IK403 Implementation Data Element Syntax Error Code This element contains the code indicating the type of error found. The values and descriptions are: 1. Required data element missing 2. Conditionally required data element missing 3. Too many data elements 4. Data element too short 5. Data element too long 6. Invalid character in data element 7. Invalid code value 8. Invalid date 9. Invalid time 10. Exclusion condition violated 12. Too many repetitions 13. Too many components I6. Code value not used in implementation I9. Implementation dependent data element missing I10. Implementation Not Used data element present I11. Implementation too few repetitions I12. Implementation pattern match failure I13. Implementation dependent Not Used data element present 12 IK404 Copy of Bad Data Element This element contains a copy of the data in error. This is a situational element that is not always provided. CTX Element Context: This segment is used to report when the error identified in this IK4 loop was triggered by a situational requirement of the Implementation Guide and the error occurs at the element level. CTX01-1 Context Name Always contains the value SITUATIONAL TRIGGER. CTX01-02 Context Reference Context Reference CTX02 Segment ID Code Code defining the segment ID of the data segment in error. 24 CTX03 Segment Position in Transaction Set This is the numerical count of this data segment from the start of the transaction set (i.e. from the start of the ST loop in the 837P file that was submitted to NYEIS). The transaction set header (i.e. the ST segment) is count position 1. CTX04 Loop Identifier Code This identifies the loop within which the error occurred on the file submitted to NYEIS. CTX05-01 Element Position in Segment This is used to indicate the relative position of a simple data element, or the relative position of a composite data structure with the relative position of the component within the composite data structure, in error. CTX05-02 Component Data Element Position in Composite Required when the situational requirement relates to a component data element within a composite data structure. CTX05-03 Repeating Data Element in Position Required when the situational requirement relates to a repeating data element. CTX06 Reference in Segment Required when CTX05 is used and the data element reference number of the data element identified in CTX05-1 is known by the submitter of the 999, and it is not a composite data element. CTX06-1 Data Element Reference Number Reference number used to locate the data element in the Data Element Dictionary. CTX06-02 Data Element Reference Number Required when CTX05-2 is used and the data element reference number of the data element identified in CTX05-2 is known. 25 Tips for Reading the F-File Response File Each error in an F-File is presented as a row of data. The position and description of the F-File columns that relate to each row of data is as follows: Column Column Name Column Description 1 Error Message A textual message describing the error. 2 Error Data The data that caused the error. 3 GS Reference The Group Control Number from the submitted file (segment GS06). 4 ISA Reference The ISA Number from the submitted file (segment ISA13). 5 Created Date The date the error message was generated in NYEIS. This date is not meant to represent the date the file was submitted to NYEIS. 6 File Name The original name of the file that was submitted to NYEIS and in which the error was detected. 7 Claim Number The Claim Reference Number (CLM01) associated with the error. This column will only be populated if the error is detected within the 2300 claim loop, which includes errors detected at the 2400 service line level. 8 SA Number The claim Service Authorization Number (2300REF02) associated with the error. This column will only be populated if its value is available at, or above, the file level where the error was detected. 9 Child Reference Number The Child Reference Number (2010BANM109) associated with the error. This column will only be populated if its value is available at, or above, the file level where the error was detected. 10 Service Date The claim service line Service Date (2400DTP03) associated with the error. This column will only be populated if its value is available at, or above, the file level where the error was detected. 837 Professional Companion Guide Page 26 F-File Error Guidance Once there are no errors generated on the 999 file, the submitted 837P is reviewed by step two of the file receipt process. Generally this step occurs within 24 hours after generating an error-free 999 response file. During this step, various pre-adjudication edit checks are performed against the data in the submitted 837P file and an F-File is generated to notify providers of any errors. For example, the ID of each rendering provider listed in the submitted file is checked for validity. The F-File is structured as a comma-delimited file that can be opened in any text editor or spreadsheet software such as Microsoft Excel for review. Textual error messages are listed in the file (e.g. The NPI reported in data element 2310BNM109 for the rendering provider is not valid ), along with additional information to describe the errors. Tips for reading the F-File are provided at the end of this document. Important - If no errors are generated during Step 2, then no F-File response will be generated. If errors are generated, then the user will need to correct the error in their file and resubmit. If the error is at the claim level, such as an invalid Service Authorization number, then only the claims affected need to be submitted on a new 837. If the error is at the header level, such as invalid ETIN, then the entire file typically needs to be resubmitted. The table below explains each of the 837P edits that may result in errors being displayed on the F-File and notes what actions are taken if an edit is exception is encountered. Please review the bolded text in the Action Taken by NYEIS if Exception Encountered column for guidance on what to do if a particular edit has been encountered and is displayed on the F-file response file. 837 Professional Companion Guide Page 27 Check for Pre-Invoice Errors Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) Test transaction not accepted in NYEIS Check for test file ISA15 (Usage Indicator) If the value is T, then the file is a test file and it will not be processed any further by NYEIS. The F-File response file produced by NYEIS will include a record indicating that this is a test file. NYEIS will STOP processing the 837P file. The 837P file must be corrected and resubmitted. Header Unable to identify receiving municipality county code (_1000B NM1 _09_Identification_Code_) Validate Municipality Code 1000BNM109 (Muni Code) If the Municipality Code cannot be found in NYEIS, then the file will not be processed any further by NYEIS. The F-File response file produced by NYEIS will include a record indicating that the county could not be found. NYEIS will STOP processing the 837P file. The 837P file must be corrected and resubmitted. Header 837 Professional Companion Guide Page 28 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) The Submitter ETIN reported in data element GS02 is not valid for the municipality code reported in data element 1000BNM109. Validate Submitter GS02 (submitter ETIN) 1000BNM109 (Muni Code) If the Submitter cannot be found in NYEIS (or the Submitter has not yet been configured by NYEIS to send electronic 837P transactions), then the file will not be processed any further by NYEIS. The F-File response file produced by NYEIS will include a record indicating that the submitter could not be found. NYEIS will STOP processing the 837P file. The 837P file must be corrected and resubmitted. Header 837 Professional Companion Guide Page 29 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) The provider has not yet been configured to submit HIPAA 4010 production files to NYEIS for the ETIN (ISA06) and Muni Code (1000BNM109) submitted in the file. Your file will not be processed any further. Validate Submitter is Configured to Submit Production Files ISA12 (HIPAA Version Indicator) ISA06 (Submitter ETIN) 1000BNM109 (Muni Code) If the submitter has not yet been configure to submit production files for the HIPAA version indicated in the file, then the file will not be processed any further by NYEIS. The F-File response file produced by NYEIS will include a record indicating that the submitter has not yet been configured to submit this version of the 837P transaction. NYEIS will STOP processing the 837P file. The 837P file must be corrected and resubmitted. 837 Professional Companion Guide Page 30 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) Unable to identify billing provider (2000A _2010AA NM1 _09_Identification_Code_) Validate Billing Provider 1000BNM109 (Muni Code) GS04 (Date) 2010AANM109 (Billing Provider NPI) If the Billing Provider cannot be found in NYEIS, or is not active in NYEIS as of the date in GS04, then no claims | /kaggle/input/edi-db-835-837/att1_rlrrn.pdf | f2f0bdd6f099893b838f4795ad4709e4 | f2f0bdd6f099893b838f4795ad4709e4_0 |
Claim) Test transaction not accepted in NYEIS Check for test file ISA15 (Usage Indicator) If the value is T, then the file is a test file and it will not be processed any further by NYEIS. The F-File response file produced by NYEIS will include a record indicating that this is a test file. NYEIS will STOP processing the 837P file. The 837P file must be corrected and resubmitted. Header Unable to identify receiving municipality county code (_1000B NM1 _09_Identification_Code_) Validate Municipality Code 1000BNM109 (Muni Code) If the Municipality Code cannot be found in NYEIS, then the file will not be processed any further by NYEIS. The F-File response file produced by NYEIS will include a record indicating that the county could not be found. NYEIS will STOP processing the 837P file. The 837P file must be corrected and resubmitted. Header 837 Professional Companion Guide Page 28 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) The Submitter ETIN reported in data element GS02 is not valid for the municipality code reported in data element 1000BNM109. Validate Submitter GS02 (submitter ETIN) 1000BNM109 (Muni Code) If the Submitter cannot be found in NYEIS (or the Submitter has not yet been configured by NYEIS to send electronic 837P transactions), then the file will not be processed any further by NYEIS. The F-File response file produced by NYEIS will include a record indicating that the submitter could not be found. NYEIS will STOP processing the 837P file. The 837P file must be corrected and resubmitted. Header 837 Professional Companion Guide Page 29 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) The provider has not yet been configured to submit HIPAA 4010 production files to NYEIS for the ETIN (ISA06) and Muni Code (1000BNM109) submitted in the file. Your file will not be processed any further. Validate Submitter is Configured to Submit Production Files ISA12 (HIPAA Version Indicator) ISA06 (Submitter ETIN) 1000BNM109 (Muni Code) If the submitter has not yet been configure to submit production files for the HIPAA version indicated in the file, then the file will not be processed any further by NYEIS. The F-File response file produced by NYEIS will include a record indicating that the submitter has not yet been configured to submit this version of the 837P transaction. NYEIS will STOP processing the 837P file. The 837P file must be corrected and resubmitted. 837 Professional Companion Guide Page 30 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) Unable to identify billing provider (2000A _2010AA NM1 _09_Identification_Code_) Validate Billing Provider 1000BNM109 (Muni Code) GS04 (Date) 2010AANM109 (Billing Provider NPI) If the Billing Provider cannot be found in NYEIS, or is not active in NYEIS as of the date in GS04, then no claims for this Billing Provider will be processed by NYEIS. The F-File response file produced by NYEIS will include a record indicating that the Billing Provider could not be found. NYEIS will STOP processing the 837P file if there are no other Billing Providers in the file. The 837P file must be corrected and resubmitted. Otherwise, NYEIS will continue processing the 837P file and attempt to validate the next Billing Provider. If the Billing Provider is not found, then NYEIS checks for the Billing Provider via use of the 2010AAREF02 segment. Dashes are supported in the identifier value for both 2010AANM109 and 2010AAREF02. The 2000A (Billing Provider) loop is allowed to repeat according to HIPAA standards. NYEIS accommodates this requirement by skipping to the end of the iteration (in case there is another Billing Provider in the file), rather than terminating the process immediately. Header 837 Professional Companion Guide Page 31 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) Submitter ETIN in ISA_06 Does not match Provider Clearing House ETIN Validate Clearinghouse ETIN ISA06 (Sender ETIN) If the Clearinghouse ETIN cannot be validated against what is in NYEIS for this provider, then no claims for this Billing Provider will be processed by NYEIS. The F-File response file produced by NYEIS will include a record indicating that the Submitter ETIN is invalid. NYEIS will STOP processing the 837P file if there are no other Billing Providers in the file. The 837P file must be corrected and resubmitted. Otherwise, NYEIS will continue processing the 837P file and attempt to validate the next Billing Provider. This validation only occurs if a provider is submitting claims through a clearinghouse. The 2000A (Billing Provider) loop is allowed to repeat according to HIPAA standards. NYEIS accommodates this requirement by skipping to the end of the iteration (in case there is another Billing Provider in the file), rather than terminating the process immediately. Header 837 Professional Companion Guide Page 32 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) Unable to identify Child (_2000A _2000B _2010BA NM1 _09_Identification_Code_) Validate Child 2010BANM109 (Child Reference Number) If the child is not found in NYEIS, then no claims for this child will be processed by NYEIS. The F-File response file produced by NYEIS will include a record indicating that the child could not be identified. NYEIS will STOP processing the 837P file if there are no other children in the file. Otherwise, NYEIS will continue processing the 837P file and attempt to validate the next Child. Any claims related to children who could not be validated by NYEIS must be corrected and resubmitted on another 837P file. Header 837 Professional Companion Guide Page 33 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) NYEIS is not currently supporting electronic adjustments or replacements to previously submitted claims Validate Claim Frequency Type Code 2300CLM0503 (Claim Frequency Type Code) If Claim Frequency Code is not equal to 1 or 8 for a particular claim, then NYEIS will log an error for that claim. The F-File response file produced by NYEIS will include a record indicating that NYEIS does not currently support electronic adjustments or replacements to previously submitted claims. NYEIS will continue processing the 837P file. Only Claim Frequency Codes 1 (original) or 8 (void) are supported by NYEIS. Claim 837 Professional Companion Guide Page 34 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) Unable to match Service Authorization number to the Child and Billing Provider Validate Service Authorization 2300REF02 (Service Authorization number where 2300REF01 G1 ) 2010BANM109 (Child Reference Number) 2010AANM109 or 2010AAREF02 (Billing Provider ID) If the Service Authorization is not found in NYEIS using the relevant data, then NYEIS will log an error for that claim. The F-File response file produced by NYEIS will include a record indicating that the Service Authorization could not be matched. NYEIS will continue processing the 837P file. Claim Invalid ICD Code Validate Diagnosis Codes 2300HI0102, 2300HI0202, 2300HI0302, 2300HI0402 (Health Care Diagnosis Code) If the Claim Diagnosis Code does not exist as an active ICD code in NYEIS, then NYEIS will log an error for that claim. The F-File response file produced by NYEIS will include a record indicating that it is an invalid Diagnosis Code. NYEIS will continue processing the 837P file. NYEIS supports up to 4 Diagnosis Codes. Any additional codes are ignored during processing. Claim 837 Professional Companion Guide Page 35 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) Referring Provider 2310A loop is missing. Confirm Referring Provider NPI exists for non-vendor based claims. 2310ANM109 (Identification Code) If the referring provider NPI is not submitted with a non- vendor based claim, then NYEIS will log an error for that claim. The F-File response file produced by NYEIS will include a record indicating that the NPI associated with the referring provider must be submitted with the claim. NYEIS will continue processing the 837P file Claim 837 Professional Companion Guide Page 36 Sample Error Test Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) The NPI reported in data element 2310ANM109 for the referring provider is not valid. Validate Referring Provider NPI 2310ANM109 (Identification Code) If the Referring Provider NPI is not formatted properly, then NYEIS will log an error for that claim. The F-File response file produced by NYEIS will include a record indicating that the NPI associated with the Referring Provider is not valid. The following criteria are used to determine if the format of the Referring Provider NPI is valid: The length of the NPI must be ten. The NPI must be numeric. The NPI must pass a checksum validation that is based on an established formula for NPIs. NYEIS will continue processing the 837P file Claim 837 Professional Companion Guide Page 37 Sample Error Test Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) The NPI reported in data element 2310BNM109 for the rendering provider is not valid. The SSN FEIN reported in data element 2310BNM109 for the rendering provider is not valid. The Reference Number reported in data element 2310BREF02 for the rendering provider is not valid. Validate Rendering Provider ID 2310BNM108 (Identification Code Qualifier) 2310BNM109 (Identification Code) OR 2310BREF02 (Reference_Identi fication_Qualifier ) 2310BREF02 (Rendering Provider Secondary Identifier) If the ID associated with the Rendering Provider is not found in NYEIS, then NYEIS will log an error for that claim. The F-File response file produced by NYEIS will include a record indicating that the ID associated with the Rendering Provider could not be identified. NYEIS will continue processing the 837P file 2310BREF01 and 2310BREF02 are only available on HIPAA 5010 transactions. 2310BREF01 must be G2. Claim 837 Professional Companion Guide Page 38 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) Referring Provider 2310A loop is missing. Confirm Referring Provider NPI exists for non-vendor based claims. 2310ANM109 (Identification Code) If the referring provider NPI is not submitted with a non- vendor based claim, then NYEIS will log an error for that claim. The F-File response file produced by NYEIS will include a record indicating that the NPI associated with the referring provider must be submitted with the claim. NYEIS will continue processing the 837P file Claim 837 Professional Companion Guide Page 39 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) The NPI reported in data element 2310ANM109 for the referring provider is not valid. Validate Referring Provider NPI 2310ANM109 (Identification Code) If the Referring Provider NPI is not formatted properly, then NYEIS will log an error for that claim. The F-File response file produced by NYEIS will include a record indicating that the NPI associated with the Referring Provider is not valid. The following criteria are used to determine if the format of the Referring Provider NPI is valid: The length of the NPI must be ten. The NPI must be numeric. The NPI must pass a checksum validation that is based on an established formula for NPIs. NYEIS will continue processing the 837P file Claim 837 Professional Companion Guide Page 40 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) The rendering provider is not a current employee contractor of the billing provider. Confirm Rendering Provider is an Employee Contractor of the Billing Provider 2310BNM108 (Identification Code Qualifier) 2310BNM109 (Identification Code) 2010AANM109 or 2010AAREF02 (Billing Provider ID) OR 2310BREF02 (Reference_Identi fication_Qualifier ) 2310BREF02 (Rendering Provider Secondary Identifier) 2010AANM109 or 2010AAREF02 (Billing Provider ID) If the Rendering Provider is not found to be an active employee contractor of the billing provider, then NYEIS will log an error for that claim. The F-File response file produced by NYEIS will include a record indicating that the Rendering Provider is not a current employee contractor of the billing provider. NYEIS will continue processing the 837P file. 2310BREF01 and 2310BREF02 are only available on HIPAA 5010 transactions. 2310BREF01 must be G2. Claim 837 Professional Companion Guide Page 41 The rendering provider NPI reported in data element 2310BNM109 is associated with more than one active employee contractor of the billing provider. The rendering provider SSN FEIN reported in data element 2310BNM109 is associated with more than one active employee contractor of the billing provider. The rendering provider Reference Number reported in data element 2310BREF02 is associated with more than one active employee contractor of the billing provider. Determine if the Reported Rendering Provider ID is Used by More Than One Active Employee Contractor of the Billing Provider 2310BNM108 (Identification Code Qualifier) 2310BNM109 (Identification Code) 2010AANM109 or 2010AAREF02 (Billing Provider ID) OR 2310BREF02 (Reference_Identi fication_Qualifier ) 2310BREF02 (Rendering Provider Secondary Identifier) 2010AANM109 or 2010AAREF02 (Billing Provider ID) If more than one active employee contractor of the billing provider is found to use the same ID reported for the rendering provider, then NYEIS will log an error for that claim. The F-File response file produced by NYEIS will include a record indicating that the ID reported for the rendering provider is associated with more than one active employee contractor of the billing provider. NYEIS will continue processing the 837P file. 2310BREF01 and 2310BREF02 are only available on HIPAA 5010 transactions. 2310BREF01 must be G2. Claim 837 Professional Companion Guide Page 42 The Procedure Code is too long or it is missing. One and only one code should be entered here. (_2400 _SV101-02) Check Length of Procedure Code 2400SV101-02 (Procedure Code) One procedure code should be reported in this segment. If the length of the procedure code is too long to be validated by NYEIS, or if the procedure code does not exist in the file, then NYEIS will log an error for that claim. The F-File response file produced by NYEIS will include a record indicating that the procedure code is too long. NYEIS will continue processing the 837P file. Claim 837 Professional Companion Guide Page 43 Check for Early Intervention Claiming Errors Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) Claim: Claim Number has an invalid rendering Provider with Reference Number: Primary Alternate ID. The rendering provider was not an active employee contractor of the billing agency on the service date. On the service date recorded in the claim, the rendering provider was not an active employee contractor of the billing provider. HIPAA Data Element (Rendering Provider Identifier) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) if the employees status of the rendering was an error and is corrected. Claim Claim: Claim Number has an invalid rendering Provider with Reference Number: Primary Alternate ID. The rendering provider is not recognized by NYEIS as an ABA Aide. Contact the Bureau of Early Intervention Provider Approval Unit for assistance. The rendering provider recorded in the claim is not recorded in NYEIS as an ABA Aide. HIPAA Data Element (Rendering Provider Identifier) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) if the restriction on the rendering was an error and is corrected. Claim Claim: Claim Number has an invalid rendering Provider with Reference Number: Primary Alternate ID. The rendering provider is not a service coordinator. The rendering provider recorded in the claim is not recorded in NYEIS as a service coordinator. HIPAA Data Element (Rendering Provider Identifier) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the issue is been corrected. Claim Claim: Claim Number has an invalid rendering Provider with Reference Number: Primary Alternate ID. The rendering provider is not approved for the Qualified Profession authorized to provide the service. Contact the Bureau of Early Intervention Provider Approval Unit for assistance. The rendering provider recorded in the claim is not approved for a Qualified Profession that is eligible to perform the service HIPAA Data Element (Rendering Provider Identifier) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) if the Qualified Profession issue was an error and is corrected. Claim 837 Professional Companion Guide Page 44 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) designated in the claim. Claim: Claim Number has an invalid rendering Provider with Reference Number: Primary Alternate ID. There was an active restriction placed on the rendering provider on the claim service date. Contact the Bureau of Early Intervention Provider Approval Unit for assistance. The rendering provider had an active restriction in place on the date of service specified in the claim. HIPAA Data Element (Rendering Provider Identifier) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) if the restriction was an error and has been corrected. Claim 837 Professional Companion Guide Page 45 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) The Provider Invoice Number is a duplicate for the Provider of Record. The invoice number is already in NYEIS on a non-voided invoice. HIPAA Data Element (Provider Invoice Number) 837 is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Header You must enter an invoice number. There is no invoice number entered. HIPAA Data Element (Provider Invoice Number) 837 is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Header You must enter a provider for the invoice. There is no provider entered on the invoice. HIPAA Data Element (Billing Provider Identification Code) 837 is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Header 837 Professional Companion Guide Page 46 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) You must enter a municipality for the invoice. There is no municipality entered on the invoice HIPAA Data Element (Muni Code) 837 is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Header You must enter a date for the invoice. There is no invoice date entered on the invoice. HIPAA Data Element (Invoice Date) 837 is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Header A borough cannot be billed on an invoice, invoices must be billed at the NYC - Citywide level. The municipality entered on the invoice corresponds to a NYC borough instead of NYC-Citywide. HIPAA Data Element (Muni Code) 837 is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Header 837 Professional Companion Guide Page 47 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) Claim Claim number has invalid times: times that caused the error The service times in the 2300 segment are not formatted in the manner that NYEIS needs them. The service times need to be in this format: CV?-hhmm-hhmm. HIPAA Data Element (Claim Note Description) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. CV? references the service type. Service times are represented by hhmm. Colons (:) cannot be used to separate hours and minutes. Claim "A Line on Claim: Claim number has an invalid procedural code: CPT Code The procedural code(CPT) entered on the claim line is not recognized as a valid code by NYEIS HIPAA Data Element (Procedure Code) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Claim 837 Professional Companion Guide Page 48 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) The Provider is not approved as of the Service Date recorded in the claim. Please contact the Bureau of Early Intervention Provider Approval Unit for assistance regarding the provider s status. The billing provider is not approved to provide the service on the service date recorded in the claim. HIPAA Data Element (Rendering Provider Identifier) HIPAA Data Element (where 2300REF01 G1 ) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) if the Approval status was an error and has been corrected. Contact the Bureau of Early Intervention, Provider Approval Unit to determine why the billing provider was not in Approved status on the claim service date. Claim There are not enough units remaining on the service authorization to cover the invoiced visit. The number of units remaining on the Service Authorization is less than the units required for the claim. Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Contact the EIO D or Service Coordinator to amend the SA and add more units. Claim 837 Professional Companion Guide Page 49 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) Service Date is outside the date range of the Service Authorization. The claim service date does not fall within the Service Authorization Start Date and End Date. HIPAA Data Element (Service Date) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Claim The Service Authorization was suspended on the date of service. The status of the service authorization specified was suspended on the date of service specified HIPAA Data Element (Service Date) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) if the SA status of suspended was an error and has been corrected. Contact the EIO D or Service Coordinator to determine why the Service Authorization or associated IFSP is has a status of Suspended. Claim 837 Professional Companion Guide Page 50 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) You must enter a service start date. No service start date is entered in the claim. HIPAA Data Element (Service Date) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Claim The service start date cannot be in the future. The service date recorded in the claim is in the future. HIPAA Data Element (Service Date) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Claim You must enter a claim start time. You must enter a claim end time. General services claims need a start and end time. HIPAA Data Element (Claim Note Description) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Claim 837 Professional Companion Guide Page 51 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) The claim start time must proceed the end time. The service start time recorded in the claim occurs after the service end time. HIPAA Data Element (Claim Note Description) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Claim You must enter a visit type. The service type in the 2300 segment is not recorded or not recognized by NYEIS. The service type needs to be in this format: CV?-hhmm-hhmm HIPAA Data Element (Claim Note Description) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. CV? References the service type. CV1 regular CV2 makeup CV3 co visit Claim You must enter a Location Type. The claim does not indicate the service location. HIPAA Data Element (Place of Service Code) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Claim 837 Professional Companion Guide Page 52 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) You must enter an ICD Diagnosis Code. HIPAA Data Element (Diagnosis Code) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Claim Provider has no active contract for the invoiced municipality. The billing provider on the invoice 1) does not have a contract with the county designated in the invoice, or 2) has a contract but it does not include the service type method associated with the Service Authorization service. HIPAA Data Element (Billing Provider Identification Code) HIPAA Data Element (Muni Code) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) if the contract issue was an error and has been corrected. Review the NYEIS contract record associated with the county designated in the invoice. Confirm that the contract is Active and includes the service type method designated in the Service Authorization. Contact the Municipality to resolve errors with the contract. Claim 837 Professional Companion Guide Page 53 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) Service date not valid. Service Coordination claim already exists on this service date. An approved claim already exists in NYEIS for service coordination for the child on this date HIPAA Data Element (Service Date) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Claim Rendering Provider must be selected for the claim. A rendering provider is not specified. HIPAA Data Element (Rendering Provider Identifier) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Claim There are not enough dollars remaining on the service authorization to cover the invoiced amount. Pertains to respite and transportation claims. The amount entered exceeds the service authorization amount. Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) after the error is corrected. Claim 837 Professional Companion Guide Page 54 Sample Error Text Description of Edit Relevant 837P Data Item(s) Used in Edit Action Taken by NYEIS if Exception Encountered Notes Relative Level of Edit (Header or Claim) The Provider Agency was restricted for this service type on the date of service. The agency or rendering provider is restricted for the product on the date of service specified. HIPAA Data Element (Billing Provider Identification Code) Claim is not uploaded to NYEIS. Submit a new 837P file (new Invoice Number) if the restriction was an error and is corrected. Contact the Bureau of Early Intervention, Provider Approval Unit to determine why the billing provider or rendering provider was restricted on the service date. Claim | /kaggle/input/edi-db-835-837/att1_rlrrn.pdf | f2f0bdd6f099893b838f4795ad4709e4 | f2f0bdd6f099893b838f4795ad4709e4_1 |
835 Health Care Claim Payment Advice Texas Medicaid HIPAA Transaction Standard Companion Guide Refers to the Implementation Guide Acute Care 835 Health Care Claim Payment Advice Based on ASC X12 version 005010 CORE v5010 Companion Guide August 2017 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 1 of 22 Disclosure Statement This document is Copyright 2015 by Texas Medicaid. 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 expressed or implied warranty. Note that the copyright on the underlying Accredited Standards Committee (ASC) X12 Standards is held by the Data Interchange Standards Association (DISA) on behalf of ASC X12. 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 2 of 22 Preface This Companion Guide to the v5010 ASC X12N Implementation Guide and associated errata adopted under Health Insurance Portability and Accountability Act of 1996 (HIPAA) clarifies and specifies the data content when exchanging electronically with Texas Medicaid. Transmissions based on this Companion Guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12N 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 Guides. NOTE: Effective January 1, 2013, health plans, covered entities and their business associates that engage in the exchange of electronic claim payment advice transactions are required by the Affordable Care Act (ACA) to comply with additional operating rule regulations for the 835 transaction. These operating rules are maintained by the Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE). 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 3 of 22 Table of Contents 1. INTRODUCTION............................................................................................................................. 4 1.1 SCOPE....................................................................................................................................... 4 1.2 OVERVIEW................................................................................................................................ 4 1.3 REFERENCES.......................................................................................................................... 5 1.4 ADDITIONAL INFORMATION................................................................................................... 5 2. GETTING STARTED........................................................................................................................ 6 2.1 WORKING WITH TEXAS MEDICAID........................................................................................ 6 2.2 TRADING PARTNER REGISTRATION.................................................................................... 6 3 CONTACT INFORMATION................................................................................................................ 7 3.1 EDI CUSTOMER SERVICE....................................................................................................... 7 3.2 EDI TECHNICAL ASSISTANCE................................................................................................ 7 3.3 PROVIDER SERVICE NUMBER............................................................................................... 7 3.4 APPLICABLE WEBSITES E-MAIL............................................................................................ 7 4. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS.......................................................... 8 5. TRADING PARTNER AGREEMENTS............................................................................................ 8 5.1 TRADING PARTNERS.............................................................................................................. 8 6. TRANSACTION SPECIFIC INFORMATION.................................................................................... 9 6.1 835 TRANSACTION.................................................................................................................. 9 Appendix A: 835 Example Transactions.......................................................................................... 18 Texas Medicaid Transaction Example:.......................................................................................... 18 NPI Transaction Example.............................................................................................................. 18 API Transaction Example.............................................................................................................. 19 Appendix B: Summary of Version Changes................................................................................. 21 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 4 of 22 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 to enable health information to be exchanged electronically and to adopt standards for those transactions. 1.1 SCOPE This Companion Guide is intended for Texas Medicaid Trading Partners interested in exchanging HIPAA compliant X12N Acute Care 835 Health Care Claim Payment Advice Transactions with Texas Medicaid. It is intended to be used in conjunction with X12N Implementation Guides and is not intended to contradict or exceed X12N standards. It is intended to be used to clarify the CORE rules and to describe the required data values to process claim payment advice transactions by Texas Medicaid. All instructions in this document are written using information known at the time of publication and are subject to change. 1.2 OVERVIEW This Companion Guide includes information needed to assist the trading partners with the submission of a valid Acute Care 835 Health Care Claim Payment Advice to Texas Medicaid in batch and real-time mode. The purpose of this document is to assist the provider with Texas Medicaid-particular data sets for information specified in the National Electronic Data Interchange Transaction Set Implementation Guide for the file type. The federal government has set standards to simplify Electronic Data Interchange (EDI). To comply with the standard, Texas Medicaid has updated the data sets for EDI files to be in accordance with HIPAA and is utilizing the ASC X12 nomenclatures. The 5010 TR3 dated April 2006 was used to create this Companion Guide for the 835 file formats. This Companion Guide is intended for trading partner use in conjunction with the ANSI ASC X12N National Implementation Guide. The ANSI ASC X12N Implementation Guides can be accessed at the Washington Publishing Company web site at: http: store.x12.org store healthcare-5010-consolidated- guides. The Texas Medicaid Companion Guide is designed to provide all entities that submit transactions regarding healthcare claims the specified data sets that Texas Medicaid requires per HIPAA compliance for the 835 file formats. Not all X12 data sets are used by Texas Medicaid to process and respond to a request for information. The Texas Medicaid EDI Connectivity Guide that contains specific instructions regarding connectivity options, along with CORE compliant Safe Harbor information, can be found on the EDI page of the Texas Medicaid website at: http: www.tmhp.com Pages EDI EDI_Technical_Info.aspx 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 5 of 22 1.3 REFERENCES This section specifies additional documents useful for the read. For example, the X12N Implementation Guides adopted under HIPAA that this document is a companion to: ACS X12 Version 5010 TR3s: http: store.x12.org store healthcare-5010-consolidated-guides CAQH CORE: http: www.caqh.org COREv5010.php 1.4 ADDITIONAL INFORMATION Security and Privacy Statement Covered entities were required to implement HIPAA Privacy Regulations no later than April 14, 2003. A covered entity is defined as a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction. Providers that conduct certain electronic transmissions are responsible for ensuring these privacy regulations are implemented in their business practices. Health and Human Services Commission (HHSC) is a HIPAA Covered Entity. Accordingly, Texas Medicaid is operating as a HIPAA Business Associate of HHSC as defined by the federally mandated rules of HIPAA. A Business Associate is defined as a person or organization that performs a function or activity on behalf of a covered entity, but is not part of the covered entity's workforce. The privacy regulation has three major purposes: 1. To protect and enhance the rights of consumers by providing them access to their health information and controlling the appropriate use of that information; 2. To improve the quality of health care in the United States by restoring trust in the health care system among consumers, health care professionals and the many organizations and individuals committed to the delivery of health care; and 3. To improve the efficiency and effectiveness of health care delivery by creating a national framework for health privacy and protection. In accordance with HIPAA privacy regulations, the state of Texas provides a Notice of Privacy Practices to all Texas Medicaid households. 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 6 of 22 2. GETTING STARTED 2.1 WORKING WITH TEXAS MEDICAID This section describes how to interact with Texas Medicaid s EDI Department. EDI Help Desk is available to assist trading partners in exchanging data with Texas Medicaid. Below are details on how to register and contact the department for assistance. 2.2 TRADING PARTNER REGISTRATION HHSC requires any entity exchanging electronic data with Texas Medicaid to be enrolled in the Texas Medicaid Program. Texas Medicaid Enrollment Forms and instructions are available at: http: www.tmhp.com Pages SupportServices PSS_Home.aspx Successful enrollment in Texas Medicaid is required before proceeding with EDI. To get started with EDI, the necessary forms and instructions are available at: http: www.tmhp.com Pages EDI EDI_Forms.aspx 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 7 of 22 3 CONTACT INFORMATION 3.1 EDI CUSTOMER SERVICE This section contains detailed information concerning EDI Customer Service, especially contact numbers. Texas Medicaid EDI Help Desk: 1-888-863-3638 The EDI Help Desk assists providers and vendors with TexMedConnect (TMC) access. The Help Desk can reset TMC passwords and troubleshoot other TMC and EDI issues such as: internet requirements, EDI enrollment, transmission verification, TMC issues, file rejection, software requests, file resets, technical problems within the Texas Medicaid website, and ER S download issues. 3.2 EDI TECHNICAL ASSISTANCE This section contains detailed information concerning EDI Technical Assistance, especially contact numbers. Texas Medicaid EDI Help Desk The EDI Help Desk provides technical assistance only by troubleshooting Texas Medicaid EDI issues. Contact your system administrator for assistance with network, hardware, or telephone line issues. To reach the Texas Medicaid EDI Help Desk, select one of the following methods: Fax 1-512-514-4230 or 1-512-514-4228 Call 1-888-863-3638 (or call 1-512-514-4150) The Texas Medicaid EDI Help Desk is available Monday through Friday, 7 a.m. to 7 p.m. CST. 3.3 PROVIDER SERVICE NUMBER This section contains detailed information concerning provider services, especially contact numbers. Provider Enrollment: 1-800-925-9126 The Provider Enrollment queue is designed to assist providers with applications to enroll and update new and existing provider accounts, and questions concerning enrollment policy. Some of the responsibilities include: maintenance of provider accounts, advising providers on how to complete a Texas Medicaid program application, and answering questions regarding policies which impact enrollment. 3.4 APPLICABLE WEBSITES E-MAIL This section contains detailed information about useful web sites and email addresses. Texas Medicaid EDI Technical Information, such as code references, vendor file specifications, and additional Companion Guides can be found at: http: www.tmhp.com Pages EDI EDI_Technical_Info.aspx 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 8 of 22 A link to the Texas Medicaid 835 EOB Crosswalk may be found at: http: www.tmhp.com Pages EDI EDI_HIPAA_Reference.aspx EDI Helpful Links: Washington Publishing Company - The Washington Publishing Company site includes reference documents pertaining to HIPAA, such as: implementation guides, data conditions, and the data dictionary for X12N standards. Workgroup for Electronic Data Interchange (WEDI) - This site provides implementation materials and information. 4. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS Texas Medicaid may split a very large amount of remittance advice information from one weekly financial cycle for a single submitter into multiple 835 files. Texas Medicaid does not support repetition of a simple data element or a composite data structure. TMHP submitter IDs will be deactivated after an inactivity period of 180 days. Submitters who wish to have their submitter IDs re-activated will need to contact the EDI Helpdesk at 1-888-863-3638. Deactivated trading partner accounts will still be able to download their Electronic Remittance and Status (ER S) Reports. 5. TRADING PARTNER AGREEMENTS This section contains general information concerning Trading Partner Agreements (TPA). 5.1 TRADING PARTNERS An EDI Trading Partner is defined as any Texas Medicaid customer (provider, billing service, software vendor, employer group, financial institution, etc.) that transmits to, or receives electronic data from, Texas Medicaid. 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. Texas Medicaid Trading Partner Agreement will be found on this web page: http: www.tmhp.com Pages EDI EDI_Forms.aspx 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 9 of 22 6. TRANSACTION SPECIFIC INFORMATION This section uses a table to describe how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed. The tables contain a row for each segment where Texas Medicaid 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 sub-set of the IGs 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 Texas Medicaid. In addition to the row for each segment, one or more additional rows are used to describe Texas Medicaid s usage for composite and simple data elements and for any other information. Notes and comments are placed at the deepest level of detail. For example, a note about a code value will be placed on a row specifically for that code value, not in a general note about the segment. This section is used to describe the required data values that will be used by Texas Medicaid for claim payment and advice regarding status of Texas Medicaid claim s. The 835 format is used for Electronic Remittance Advice (ERA) and or payments. This is the file that is sent from Texas Medicaid to the billing providers. 6.1 835 TRANSACTION Page Loop ID Reference Name Codes Length Notes Comments Control Segments C.3 ISA Interchange Control Header C.4 ISA01 Authorization Information Qualifier 00 C.4 ISA03 Security Information Qualifier 00 C.4 ISA05 Interchange ID Qualifier ZZ C.4 ISA06 Interchange Sender ID Production 617591011C21P Testing 617591011C21T This is Texas Medicaid s Electronic Transmitter Identifier. C.5 ISA07 Interchange ID Qualifier ZZ C.5 ISA11 Repetition Separator (pipe character) 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 10 of 22 Page Loop ID Reference Name Codes Length Notes Comments ISA14 Acknowledgment Requested 0 (zero) C.6 ISA15 Interchange Usage Indicator P Texas Medicaid populates "P" in ISA15 for both production and test data. ISA16 Component Element Separator: (colon character) BPR Financial Information BPR01 Transaction Handling Code H, I Texas Medicaid populates H in BPR01 if BPR04 NON, and populates I in BPR01 if BPR04 ACH or CHK. BPR03 Credit Debit Flag Code C BPR04 Payment Method Code ACH, CHK, NON BPR05 Payment Format Code CCP Texas Medicaid populates BPR05 with CCP if BPR04 ACH; otherwise BPR05 is not populated. REF Version Identification REF02 Reference Identification 0001 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 11 of 22 Header 102 1000B N1 Payee Identification 103 1000B N103 Identification Code Qualifier XX, FI N103 will contain XX if the National Provider Identifier (NPI) is present in N104. N103 will contain FI if the Atypical Provider Identifier (API) is present in REF02. 103 1000B N104 Identification Code 9 or 10 numeric N104 will contain the billing provider s assigned EIN if N103 FI. N104 will contain the billing provider s assigned NPI if N103 XX. 107 1000B REF Payee Additional Identification 107 1000B REF01 Reference Identification Qualifier OB, TJ, D3, PQ REF01 will contain "OB" if the State License Number is present in REF02. REF01 will contain TJ if the EIN is present in REF02. REF01 will contain "D3" if the NCPDP is present in REF02. REF01 will contain PQ if the Taxonomy is present in REF02. 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 12 of 22 108 1000B REF02 Reference Identification 9 numeric or 10 alphanumeric REF02 will contain the billing provider assigned state license number if REF01 "OB". REF02 will contain the billing provider s assigned Federal Taxpayer s Identification Number if REF01 TJ and N103 XX. REF02 will contain the billing provider assigned NCPDP if REF01 "D3". REF02 will contain the billing provider s assigned taxonomy that is on file with Texas Medicaid if REF01 PQ. 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 13 of 22 Detail 123 2100 CLP Claim Payment Information There can be a maximum of 10,000 CLP segments per ST SE transmitted on the 835. 2100 CLP02 Claim Status Code To determine the full claim status, reference Claim Adjustment Reason Codes in the CAS segment and Remittance Advice Remark Codes in the LQ segments in conjunction with the claim status code in CLP02. 2100 NM1 Patient Name 2100 NM108 Identification Code Qualifier MI Texas Medicaid populates NM108 with MI. 2100 NM109 Identification Code Texas Medicaid populates NM109 with the patient s Texas Medicaid ID. 169 2100 REF Other Claim Related Identification 170 2100 REF02 Reference Identification CA1, CCP, CSN, DE1, DM2, DM3, EC1, EP1, FP3, HA1, IM1, MA1, MH2, MTP, TB1, WC1 3 alphanumeric REF02 will contain the Benefit Code that was submitted on the inbound 837 transaction if REF01 G3. The benefit code will be one of the following values if applicable and if submitted on the 837 transaction: CA1: County 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 14 of 22 Indigent Health Care Program (CIHCP) CCP: Comprehensive Care Program (CCP) CSN: Children with Special Health Care Needs (CSHCN) Services Program Provider DE1: Texas Health Steps (THSteps) Dental Provider DM2: Durable Medical Equipment (DME) DM3: DME for CSHCN Providers EC1: Early Childhood Intervention (ECI) Provider EP1: THSteps Medical Provider FP3: Family Planning, Primary Home Care (PHC) HA1: Hearing Aid IM1: Immunization Clinic MA1: Maternity MH2: Mental Health (MH) Case Management MTP: Medical Transportation Provider TB1: Tuberculosis (TB) Clinic WC1: Women, 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 15 of 22 Infants, and Children (WIC) Clinic 2100 PER Claim Contact Information 2100 PER02 Name MEDI, STAR, CIDC, FP05, FP10, FP20 4 alphanumeric PER02 will contain the program code the claim was paid under. 2100 PER04 Communication Number PER04 will contain the contact phone for the program the claim was paid under. 2100 AMT Claim Supplemental Information 2100 AMT01 Amount Qualifier Code DY, AU 184 2100 QTY Claim Supplemental Information Quantity 185 2100 QTY02 Quantity 3 numeric QTY02 will contain the Quantity Allowed if QTY01 CA. Service Payment Information 207 2110 REF Rendering Provider Information 208 2110 REF01 Reference Identification Qualifier HPI, 1D REF01 will contain HPI if the NPI is present in REF02. REF01 will contain 1D if the API is present in REF02. 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 16 of 22 208 2110 REF02 Reference Identification 10 numeric or 10 alphanumeric REF02 will contain the rendering provider s assigned NPI if REF01 HPI. REF02 will contain the rendering provider s assigned API if REF01 1D. 2110 LQ Health Care Remark Codes 2110 LQ01 HE 2110 LQ02 Texas Medicaid populates LQ02 with the Remittance Advice Remark Code if LQ01 HE. To determine the full claim status, reference Claim Adjustment Reason Codes in the CAS segment and Remittance Advice Remark Codes in the LQ segments in conjunction with the claim status code in CLP02. 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 17 of 22 Service Adjustment 217 PLB Provider Adjustment 218 PLB01 Reference Identification 10 numeric or 10 alphanumeric PLB01 will contain the provider s assigned Payee NPI, or the provider s assigned Payee API. 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 18 of 22 Appendix A: 835 Example Transactions Details: One 835 transaction reflects a single payment (check or EFT), or one 835 per pay-to provider. Both paid and denied claims will be reported in the 835. Pended claims will be reported in the Claim Status Pending Remittance (277P) and will be transmitted in the same envelope as the 835. Texas Medicaid Note: In the following examples, carriage return line feeds are inserted after the character for improved readability purposes. Texas Medicaid Transaction Example: NPI Transaction Example ISA 00 00 ZZ 617591011C21P ZZ 012345678 131231 0856 00501 004171656 0 P: GS HP 617591011C21P 012345678 20131231 1716 5171655 X 005010X221A1 ST 835 0001 BPR I 50.80 C CHK 20131231 TRN 1 020961585 1123456789 REF EV 012345678 REF F2 0001 DTM 405 20131231 N1 PR Texas Medicaid Healthcare Services N3 12365A Riata Trace Parkway N4 Austin TX 787276524 PER BL EDI HELPDESK TE 8888633638 N1 PE ORGANIZATION NAME XX 1234567890 N3 100 MAIN STREET N4 TOWN TX 12345 REF TJ 123456789 REF PQ 999999999X PLB 1234567890 20130101 50:0652011042701 15.25 51:0652011042702 20.1 SE 17 0001 ST 835 0002 BPR I 52.07 C CHK 20130217 TRN 1 020961585 1123456789 REF EV 123456789 REF F2 0001 DTM 405 19991231 N1 PR Texas Medicaid Healthcare Services N3 12365A Riata Trace Parkway N4 Austin TX 787276524 PER BL EDI HELPDESK TE 8888633638 N1 PE ORGANIZATION NAME XX 1234567890 N3 100 MAIN STREET N4 TOWN TX 12345 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 19 of 22 REF TJ 123456789 REF PQ 999999999X LX 1 CLP 98765432 1 50.80 50.80 MC 100020030201411122222333 11 1 6401 0 1 NM1 QC 1 LASTNAME FIRSTNAME M MI 123456789 NM1 74 1 C 123456789 NM1 PR 2 OTHER INSURANCE NAME1 PI 123456789 REF EA 123456Q REF SY 123456789 REF F8 100020030201422233333444 REF G1 1234567890 REF G3 CCP DTM 232 20130120 DTM 233 20131231 PER CX MEDI TE 5127941234 AMT AU 3897.51 QTY CA 2 SVC HC:99215 50.8 50.8 DTM 472 20131231 REF HPI 1234567890 PLB 1234567890 20131231 CS:20143111022222 -1.27 SE 35 0002 GE 2 5171655 IEA 1 004171656 API Transaction Example ISA 00 00 ZZ 617591011C21P ZZ 012345678 131231 0856 00501 004171656 0 P: GS HP 617591011C21P 012345678 20131231 1716 5171655 X 005010X221A1 ST 835 0001 BPR I 15.45 C CHK 20130717 TRN 1 020961585 1234567890 REF EV 123456789 REF F2 0001 DTM 405 20131231 N1 PR Texas Medicaid Healthcare Services N3 12365A Riata Trace Parkway N4 Austin TX 787276524 PER BL EDI HELPDESK TE 8888633638 N1 PE ORGANIZATION NAME FI 123456789 N3 100 MAIN STREET N4 TOWN TX 12345 REF D1 A123456789 REF PQ 999X99999X LX 1 CLP PAT ACCT NUMBER11111 1 50.80 50.80 MC 100020030201311122222333 12 A 10 2.25 NM1 QC 1 LASTNAME FIRSTNAME M MI 123456789 NM1 74 1 C 123456789 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 20 of 22 NM1 PR 2 OTHER INSURANCE NAME1 PI 123456789 REF EA 11111111 REF SY 123456789 REF F8 100058030201422233333444 REF G1 1234567890 DTM 232 20131201 DTM 233 20131231 PER CX MEDI TE 5127941234 AMT AU 9999.89 QTY CA 2 SVC HC:99215 50.8 50.80 DTM 472 20131231 REF 1D A123456789 PLB A123456789 20131231 50:0652011042701 15.25 51:0652010012702 20.10 SE 34 0001 GE 1 5171655 IEA 1 004171656 835 Health Care Claim Payment Advice Texas Medicaid Healthcare Partnership Page 21 of 22 Appendix B: Summary of Version Changes The following is a log of changes made since the original version of the document was published. Change Date 1 Example transactions updated. 07 07 2014 2 CAQH CORE language and table added. 10 08 2014 3 Numerous corrections and format consistency changes. Updated contact information p. 8. Added link to EOB Crosswalk p. 9. BPR segment details added p. 11. MIA segment removed as it is not used by Texas Medicaid. Updated added codes for loop 2100 REF, PER, AMT, and QTY and loop 2110 LQ segments pp. 14-17. Updated example transactions pp. 19-21. 7 30 2015 4 Added TMHP submitter IDs will be deactivated after an inactivity period of 180 days. Submitters who wish to have their submitter IDs re-activated will need to contact the EDI Helpdesk at 1-888-863-3638. Deactivated trading partner accounts will still be able to download their Electronic Remittance and Status (ER S) Reports. on p. 5 04 13 2016 5 Removed Option; Option 2 from Provider Enrollment Phone: 1-800-925- 9126, Option 2 Section 3.3. page 8 Removed all other Phone Number Options from 3.1 3.2 06 21 2016 10 06 2016 6 Removed reference of EPHC: Expanded PHC (EPHC) Provider on page 14 of 22. 01 10 2017 7 Removed reference to data values 1, 4, 22, 25 from 2100 CLP02 on Page 13 of 22. Changes to be effective 08 25 17 05 15 2017 | /kaggle/input/edi-db-835-837/835 ACUTE CARE COMPANION GUIDE_5010.pdf | f685a5b3d46aa770cfd72e2a02afd0e8 | f685a5b3d46aa770cfd72e2a02afd0e8_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 837 Health Care Claim: Institutional (X223A3) 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 1 586 View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view security-health health-care-claim-institutional- x223a3 01H25JWH4ZF11XGRZE8AV514TR POWERED BY Build EDI implementation guides at stedi.com 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 2 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 3 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 4 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 5 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 6 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 7 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 8 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 9 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 10 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 11 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 12 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 13 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 14 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 15 586 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 0618 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 16 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 17 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 18 586 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HC XXX XXXX 20250131 0142 0 XX 005010X223A3 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) 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 19 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 20 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 21 586 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 20250130 0152 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. 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 22 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 23 586 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 XXXX XXXXXX XXXXX 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 24 586 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 Enter the same value as ISA06, the nine-digit submitter number assigned by Security Health Plan 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 25 586 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 XXXXXX EM X EX XX EM XXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 26 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 27 586 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 Security Health Plan 46 39045 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 Security Health Plan 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 Usage notes Enter the same value as GS03, SHP, or 39045 for Security Health Plan 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 28 586 1000B Receiver Name Loop end Heading end 39045 SHP 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 29 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 30 586 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 XXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 31 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 32 586 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 XXXXXX XX XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 33 586 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 National Provider ID for the billing provider 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 34 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 35 586 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 XXXXX XX XXXXXX 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 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_0 |
(ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 33 586 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 National Provider ID for the billing provider 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 34 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 35 586 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 XXXXX XX XXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 36 586 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 37 586 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 Usage notes Enter the Employer Identification Number (tax ID for the billing provider) 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 38 586 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 XXX EX X EM 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 39 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 40 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 41 586 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 XXX XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 42 586 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 XXXXXXXX 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 43 586 2010AB Pay-to Address Name Loop end 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 44 586 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 XXX 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 45 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 46 586 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 X XXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 47 586 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 XXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 48 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 49 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 50 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 51 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 52 586 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 XXX XXXXXX 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) 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 53 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 54 586 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 XXX XXXXXX X XXXXXX 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 55 586 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) 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 12 String (AN) Optional Code identifying a party or other code Usage notes Enter the recipient s 12-digit Subscriber Number. Security Health Plan Member ID. Note: do not enter any other numbers or letters. Use the SHP identification card. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 56 586 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 XXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 57 586 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 XXXXXX XX XXXXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 58 586 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 59 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 60 586 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 XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 61 586 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 62 586 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 XXXXXX PI SHP 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 63 586 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 String (AN) Required Code identifying a party or other code Usage notes Enter SHP for Security Health Plan s Primary Payer Identification. Other acceptable values are 39045 and 35202 (this value should be used only for Security Administrative Services claims). 35202 39045 SHP 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 64 586 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 X 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 65 586 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 XXXXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 66 586 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 67 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 68 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 69 586 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 000000 XX A 7 C W I 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. CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 70 586 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. Enter the total billed amount for the entire 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 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 Use the claim frequency code to indicate if the claim is being submitted for the first time or if it is a replacement or void of a previously submitted claim. Enter the value 1 to indicate it is the first time a claim is submitted to Security Health Plan. Enter the value 7 to indicate this claim is replacing a previously submitted claim. Enter the value 8 to indicate the previously submitted claim is to be voided. 1 The first time a claim is submitted to Security Health Plan 7 This claim is replacing a previously submitted claim 8 The previously submitted claim is to be voided CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 71 586 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-20 1514 Delay Reason Code Identifier (ID) Optional 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 72 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 73 586 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 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. 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 74 586 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 XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 75 586 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 XXX 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 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_1 |
- Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 73 586 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 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. 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 74 586 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 XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 75 586 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 XXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 76 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 77 586 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 X 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 78 586 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 NN 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 79 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 80 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 81 586 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 05 000000000 00 X 000000 XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 82 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 83 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 84 586 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 XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 85 586 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 XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 86 586 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 XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 87 586 The value carried in this element is limited to a maximum of 20 positions. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 88 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 89 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 90 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 91 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 92 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 93 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 94 586 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 95 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 96 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 97 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 98 586 6 Request for Override Pending 7 Special Handling 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 99 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 100 586 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 XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 101 586 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 SPT X 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 102 586 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 ST XX XXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 103 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 104 586 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 ABJ 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 105 586 Code indicating a 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 106 586 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 XXX BG XXXXX BG XXX BG XXXXX BG XXX BG XXXX XX BG XXXXXX BG XXXXX BG XXXXX BG XXXX BG XXXXX X BG 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 107 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 108 586 C022-01 1270 Code List Qualifier Code 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 109 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 110 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 111 586 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 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_2 |
30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 110 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 111 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 112 586 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 XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 113 586 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 XXXX N ABN X Y BN XXX N BN XXX N BN XXXXXX N ABN XXXX W ABN X U ABN XXXXX U BN X N ABN X Y BN XXXXX U 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 114 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 115 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 116 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 117 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 118 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 119 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 120 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 121 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 122 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 123 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 124 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 125 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 126 586 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 X D8 XXXXXX BH XXXXX D8 XXX BH XXX D8 XXX X BH XX D8 XXXXX BH XXXX D8 XXXXX BH XXXXXX D 8 X BH XXXXX D8 XXXX BH XXXX D8 XXXXX BH XXXX D 8 XX BH XXXXXX D8 XXXXX BH XXXXX D8 XXXX BH XXXXX X 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 127 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 128 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 129 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 130 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 131 586 Code indicating a 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 132 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 133 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 134 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 135 586 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 XX RD8 XXXX BI XXXXX RD8 XXXXXX BI XXXXXX R D8 X BI X RD8 XXXXX BI X RD8 X BI XXXXXX RD8 XXXX XX BI XXXX RD8 XXXXX BI XXX RD8 XXXXXX BI X RD8 X XX BI XXX RD8 XXX BI XXX RD8 XXX BI XX RD8 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 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 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_3 |
30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 134 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 135 586 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 XX RD8 XXXX BI XXXXX RD8 XXXXXX BI XXXXXX R D8 X BI X RD8 XXXXX BI X RD8 X BI XXXXXX RD8 XXXX XX BI XXXX RD8 XXXXX BI XXX RD8 XXXXXX BI X RD8 X XX BI XXX RD8 XXX BI XXX RD8 XXX BI XX RD8 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 136 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 137 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 138 586 Code indicating a 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 139 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 140 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 141 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 142 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 143 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 144 586 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 XXXXXX N ABF XX Y BF XXXXXX N ABF X U BF XX N BF XXX W A BF XX W BF XXX W ABF XXXXX Y AB F X Y BF XXX N ABF XXX Y 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 145 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 146 586 Code indicating a 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 147 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 148 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 149 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 150 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 151 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 152 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 153 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 154 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 155 586 C022-01 1270 Code List Qualifier Code 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 156 586 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 XXX D8 XX BQ XXXX D8 XXXXX BBQ XX D8 XX BB Q XXX D8 XXXXXX BQ XXXXXX D8 XX BQ XXXXX D8 XXXX X BQ XXXXXX D8 XXXXX BBQ XXXXXX D8 XX BQ XX D8 XX X BQ XXX D8 XXXXXX BQ XXX D8 XXXXX BBQ XXXXXX D 8 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, 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 157 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 158 586 Code indicating a 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 Security Health | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_4 |
Code 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 158 586 Code indicating a 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 159 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 160 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 161 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 162 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 163 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 164 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 165 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 166 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 167 586 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 XX APR XXXXXX PR 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 168 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 169 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 170 586 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 XXXX U 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 171 586 Code indicating a 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 172 586 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 BBR XX D8 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 173 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 174 586 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 XX TC XXX TC XXXX TC XXXX TC XXXXX TC XXXXX X TC XXXXX TC XXXXXX TC X TC XX TC XXXXXX 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 175 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 176 586 C022-01 1270 Code List Qualifier Code 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 177 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 178 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 179 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 180 586 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 XXXXXX 0000000 BE XXXX 00000000000000 0 BE XX 000000000000 BE XXXXXX 0000000000000 0 BE XXXXXX 0000000000000 BE XXXXXX 000000000 00 BE XXXXXX 00000000000000 BE XXXXXX 000 B E X 000000000000 BE XXX 0000000000 BE X 00 0 BE XX 000 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 181 586 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-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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 182 586 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-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. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 183 586 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-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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 184 586 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-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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 185 586 C022-01 1270 Code List Qualifier Code 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-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 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_5 |
not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 184 586 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-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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 185 586 C022-01 1270 Code List Qualifier Code 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-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 Max use 1 Optional 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 186 586 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. C022-01 1270 Code List Qualifier Code 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 187 586 Monetary amount 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 188 586 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 01 00000000000 000000000000 XXX 0 XXX 000 XX X UN 00000000 T3 2 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 189 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 190 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 191 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 192 586 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 XXX XXXX XX XXXX XX XXXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 193 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 194 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 195 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 196 586 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 XXXXXX XX XX XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 197 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 198 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 199 586 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 XXX X XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 200 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 201 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 202 586 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 XXXX XX XX XXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 203 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 204 586 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 205 586 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 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 206 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 207 586 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 XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 208 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 209 586 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 210 586 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 211 586 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 X X XXXX XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 212 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 213 586 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 214 586 2320 Other Subscriber Information Loop Max 10 Optional Usage notes Include this loop if the claim will be processed by multiple payers 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 U 18 XXXXX X 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) Required 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 215 586 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 MA Medicare Part A MB Medicare Part B 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 216 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 217 586 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). Include this segment when another payer has made payment at the claim level Example CAS PR X 00000000000000 00000000000000 XXX 000000 0000000 0000 XXX 000 00000000000000 XXXXX 00000 0 000 XXX 00000 000000 XX 00000000000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 218 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 219 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 220 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 221 586 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 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_6 |
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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 219 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 220 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 221 586 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.; This segment contains the amount paid on this claim by the payer within this 2320 loop. Example AMT D 0000000000000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 222 586 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 0000000000000 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 Usage notes Enter the amount paid on this claim by the payer 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 223 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 224 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 225 586 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 000000 0000 00 XXXXXX 0000000 000 00000000 0 00000000000000 00000000000 000000000000 000 00000 00000 00000000 00000000000000 00000000000 000 0 0 0000000000 XX XXXXXX XXXXX XXXXXX 0 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 226 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 227 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 228 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 229 586 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 0000000 00 XXXXXX XXXXX XX X XX 000000000000 0 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 230 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 231 586 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 XXXX XXX XXXX X II 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 232 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 233 586 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 XXXX XXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 234 586 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 XXXXXXX XX XXXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 235 586 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 236 586 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 XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 237 586 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. This segment contains information on the other payer. Example NM1 PR 2 XXXX 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) 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 238 586 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.; Enter the other payer s identifier 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 239 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 240 586 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 XXXXXX XX XXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 241 586 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 242 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 243 586 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 Only allowed value is "Y". 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 244 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 245 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 246 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 247 586 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 NF 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 248 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 249 586 1 Person 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 250 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 251 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 252 586 1 Person 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 253 586 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 1G XXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 254 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 255 586 1 Person 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 256 586 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 XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 257 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 258 586 2 Non-Person Entity 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 259 586 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 LU X 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, | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_7 |
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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 257 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 258 586 2 Non-Person Entity 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 259 586 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 LU X 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 260 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 261 586 1 Person 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 262 586 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 1G XXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 263 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 264 586 1 Person 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 265 586 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 G2 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 266 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 267 586 2 Non-Person Entity 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 268 586 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 LU XXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 269 586 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 270 586 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 XX HC XXXXXX XX XX XX XX XXXXXX 00000000000 0 UN 0000000000 00 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. Enter the revenue code for the service performed. 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.; Enter a healthcare Common Procedural coding system (HCPCS) code, when necessary to supplement the revenue code 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. 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 271 586 Enter the HCPCS CPT code for the procedure performed 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. Usage notes Enter a HCPCS CPT modifier code, if necessary to clarify the procedure code. 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. Usage notes Enter a HCPCS CPT modifier code, if necessary to clarify the procedure code. 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 Enter a HCPCS CPT modifier code, if necessary to clarify the procedure code. 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. Usage notes Enter a HCPCS CPT modifier code, if necessary to clarify the procedure code. 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 272 586 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. Enter the billed amount for the service line 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. Enter the number of minutes or units for the services provided 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 273 586 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 CT FX AC XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 274 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 275 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 276 586 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 X 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 277 586 Usage notes Enter the date(s) the procedure was performed 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 278 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 279 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 280 586 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 XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 281 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 282 586 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 000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 283 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 284 586 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 04 00000000000000 00000 XX 0000000 XX 0000000 000 XXXXX IV X UN 0000000000 T3 2 5 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 285 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 286 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 287 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 288 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 289 586 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 X 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 290 586 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 00000000000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 291 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 292 586 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 XXX XXXX XXXXX XXXXX XX XXXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 293 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 294 586 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 G2 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 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 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_8 |
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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 293 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 294 586 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 G2 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 295 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 296 586 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 XXXXX XXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 297 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 298 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 299 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 300 586 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 XXXX XX XX XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 301 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 302 586 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 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 303 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 304 586 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 XXXXX X XX 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 305 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 306 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 307 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 308 586 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 XXXXXX 00000 IV XX XX XX XX XX XXXXXX X 00000 0000000000 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). Enter the other payer s primary identifier if another payer has paid on the service line 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. Enter the amount the other payer paid on the service line 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 Max use 1 Optional 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 309 586 Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01). 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. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 310 586 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-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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 311 586 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 312 586 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). Include this segment when another payer has made payment at the service line. Example CAS CR XXXXX 0 00000000000000 XXXX 0 000000000000 0 XXXX 000000000000000 00000000000 XX 00000000000 00 000000 X 0000 0000000000 XXXX 000000000000 00 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 5 Optional 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 313 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 314 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 315 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 316 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 317 586 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 000000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 318 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 319 586 0 No Subordinate HL Segment in This Hierarchical Structure. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 320 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 321 586 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 Usage notes Enter information about the patient in this loop (if different from the subscriber) Example NM1 QC 1 XXXXXX XXX XXXXXX 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 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 322 586 Suffix to individual name 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 323 586 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 XX 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 324 586 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 XXXXXXX XXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 325 586 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 X 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 326 586 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 X 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 327 586 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 XXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 328 586 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 XXXXXX 000000 XX A X B Y Y 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 329 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 330 586 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 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_9 |
number (R) Required 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 329 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 330 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 331 586 15 Natural Disaster 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 332 586 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 XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 333 586 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 XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 334 586 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 XXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 335 586 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 XXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 336 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 337 586 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 AS 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 338 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 339 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 340 586 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 09 00000000000000 00000 XXXXX 0000 XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 341 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 342 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 343 586 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 XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 344 586 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 XXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 345 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 346 586 The value carried in this element is limited to a maximum of 20 positions. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 347 586 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 XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 348 586 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 349 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 350 586 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 351 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 352 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 353 586 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 354 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 355 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 356 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 357 586 6 Request for Override Pending 7 Special Handling 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 358 586 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 359 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 360 586 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 DGN XXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 361 586 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 NU 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 362 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 363 586 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 ABJ XXXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 364 586 Code indicating a 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 365 586 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 XXXXX BG XX BG XXXXX BG XXXXX BG XXX B G XXXXXX BG XXX BG XXX BG XX BG XXX BG 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 Usage notes Max use 1 Optional 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 366 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 367 586 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 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_10 |
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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 367 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 368 586 Code indicating a 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 369 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 370 586 C022-01 1270 Code List Qualifier Code 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 371 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 372 586 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 BN XX W ABN XXXXX W ABN XX Y ABN XXX Y ABN XXX Y ABN XXX W ABN XXXXXX Y BN XX N ABN XXXX W BN XXXX Y BN XXXXX W BN 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 373 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 374 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 375 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 376 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 377 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 378 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 379 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 380 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 381 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 382 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 383 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 384 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 385 586 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 XXXX D8 XXXX BH XXX D8 XXX BH X D8 XX BH X X D8 XXXXX BH XXX D8 X BH XX D8 XXXXXX BH XXX D 8 XX BH X D8 XXXXXX BH XX D8 XXXXXX BH XXXX D8 XX XXX BH XXXX D8 XX BH XXXXX D8 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 386 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 387 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 388 586 Code indicating a 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 389 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 390 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 391 586 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 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_11 |
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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 391 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 392 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 393 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 394 586 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 XX RD8 XXXXX BI XXXX RD8 X XX BI X RD8 XXXXXX BI X RD8 X BI XXXX RD8 X BI X X RD8 XXXXXX BI XXXX RD8 XXXXX BI XX RD8 X BI XXX X RD8 X BI XXX RD8 XXXXXX BI XXXXX RD8 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 395 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 396 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 397 586 Code indicating a 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 398 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 399 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 400 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 401 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 402 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 403 586 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 ABF X N ABF X W BF XX W AB F XX Y ABF XX W BF XXXXX W AB F X W BF XXXXXX U BF XXXXXX U A BF XX U ABF XX Y BF XXXXXX 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 404 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 405 586 Code indicating a 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 406 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 407 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 408 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 409 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 410 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 411 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 412 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 413 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 414 586 C022-01 1270 Code List Qualifier Code 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 415 586 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 BQ XX D8 X BBQ XXX D8 XXXXXX BBQ XXXXXX D8 XXX X | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_12 |
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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 414 586 C022-01 1270 Code List Qualifier Code 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 415 586 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 BQ XX D8 X BBQ XXX D8 XXXXXX BBQ XXXXXX D8 XXX X BQ XXXXX D8 XXXXX BBQ XXXXX D8 XXXX BQ XXXXXX D 8 XXXXX BQ XXXX D8 XXXX BQ XX D8 XXXXX BQ XX D8 X XXXXX BQ XXXXX D8 X BBQ XXXXX D8 XX BBQ XX D8 XXX 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 416 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 417 586 Code indicating a 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 418 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 419 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 420 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 421 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 422 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 423 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 424 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 425 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 426 586 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 XX APR XXXXXX APR 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 427 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 428 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 429 586 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 ABK X U 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 430 586 Code indicating a 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 431 586 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 BR 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 432 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 433 586 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 XX TC XX TC XXXX TC X TC XXXXX TC XXXXXX T C XX TC XXX TC XX TC XXXX TC XXX TC 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 434 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 435 586 C022-01 1270 Code List Qualifier Code 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 436 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 437 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 438 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 439 586 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 X 000000000 BE XXXX 0 BE XX 000000000 000 BE XXXX 00000000000 BE XXXX 0000000000000 00 BE XXXXX 000000 BE XXXX 000000000000 BE XX XX 0 BE XX 0000 BE X 0000 BE XX 000000000 000000 BE XXXXX 0000000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 440 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 441 586 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, | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_13 |
1270 Code List Qualifier Code 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 440 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 441 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 442 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 443 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 444 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 445 586 C022-01 1270 Code List Qualifier Code 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 446 586 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 447 586 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 02 000000 000000000000 XXXXXX 0000 XXX 000000 000 XXXXX UN 00000000000000 T4 5 5 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 448 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 449 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 450 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 451 586 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 XXXX XXXX XXXX XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 452 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 453 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 454 586 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 G2 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 455 586 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 XXXXXX XX XXXXXX XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 456 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 457 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 458 586 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 X X XXX XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 459 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 460 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 461 586 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 XXXXXX XXX XX XXXXX XX XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 462 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 463 586 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 LU 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 464 586 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 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 NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 465 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 466 586 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 XXXXX XXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 467 586 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 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 Code identifying the country subdivision Usage notes 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 468 586 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 469 586 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 470 586 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 XXXXX XXXX XXXX XXX 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 471 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 472 586 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 0B 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 473 586 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 XXXX X 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 474 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 475 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 476 586 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 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_14 |
Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 474 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 475 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 476 586 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 CR XX 0000000000000 00000000 XXXX 0000000000 0 000000000000000 XXX 00000000000 00000000000000 0 XXX 00000000000 0000000 XXXX 0000000 00000000 X X 000000000000 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 Max use 5 Optional 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 477 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 478 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 479 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 480 586 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 0000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 481 586 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 482 586 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 0000000000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 483 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 484 586 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 0000000000000 0000000 000000000 XXXXXX 0000 0 000 00 000000000 000000 00000000 00000000 00000 00 00000000000 000000 0000000000000 0 0000 000000 0000000 XXXXX X X XX 0000000000000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 485 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 486 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 487 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 488 586 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 000 0000 XXX XXXXX X XX XXXX 00000000 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 489 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 490 586 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 XX XXXXXX XX 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 491 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 492 586 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 XXXXXX 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 493 586 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 XXXXX XX XXX 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 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 494 586 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 495 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 496 586 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 XXXX XV 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 497 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 498 586 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 499 586 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 XXXXXXXX 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 500 586 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 501 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 502 586 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 Only allowed value is "Y". 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 503 586 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 XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 504 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 505 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 506 586 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 XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 507 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 508 586 1 Person 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 509 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 510 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 511 586 1 Person 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 512 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 513 586 2330E Other Payer Other Operating Physician Loop Max 1 Optional Variants (all may be used) Other Subscriber Name Loop Other Payer Name Loop Other | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_15 |
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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 511 586 1 Person 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 512 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 513 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 514 586 1 Person 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 515 586 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 G2 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 516 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 517 586 2 Non-Person Entity 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 518 586 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 XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 519 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 520 586 1 Person 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 521 586 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 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 522 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 523 586 1 Person 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 524 586 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 525 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 526 586 2 Non-Person Entity 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 527 586 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 XXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 528 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 529 586 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 IV XXXX XX XX XX XX X 000000000000000 DA 0 000000000 000000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 530 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 531 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 532 586 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 OD BM AC XXXXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 533 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 534 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 535 586 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 RD8 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 536 586 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 537 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 538 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 539 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 540 586 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 0000000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 541 586 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 00000000000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 542 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 543 586 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 10 00000000 0000000 XXX 00 XXXXXX 00000000 XX XXX HP XXXX UN 000000000000000 T2 5 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 544 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 545 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 546 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 547 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 548 586 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 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_16 |
01H25JWH4ZF11XGRZE8AV514TR 546 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 547 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 548 586 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 549 586 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 00000000000000 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 550 586 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 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 551 586 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 XXXX XXX XXXXXX XXXXXX XX XXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 552 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 553 586 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 XXXXX 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 554 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 555 586 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 X XXXXXX XXXX XXXXX XX XX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 556 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 557 586 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 1G X 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 558 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 559 586 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 XXXX XXXX XXXX XXXXXX XX XXX 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 560 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 561 586 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 0B XXX 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 562 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 563 586 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 XXXXX XXX X X 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 564 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 565 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 566 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 567 586 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 XXXXX 00000000 HC X XX XX XX XX XXXXX XXXX X 0 000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 568 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 569 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 570 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 571 586 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 PI XX 0000000 000000 XX 0000000 0000000000000 00 XX 000000000000 000000000 XXXXX 00 000000 XX X 00000000000000 000000000000 X 00000000000000 00 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 Max use 5 Optional 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 572 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 573 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 574 586 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 575 586 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 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 576 586 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 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 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 577 586 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 000000000 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 Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 578 586 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 00000 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 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 579 586 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 580 586 EDI Samples Example 1a: Institutional Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231103 0222 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231103 022254 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 Security Health Plan 46 39045 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 35202 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 581 586 Example 1b: Two Claims for the Same Provider ISA 00 00 ZZ SENDER ZZ RECEIVER 231103 0222 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231103 022254 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 Security Health Plan 46 39045 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 35202 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 35202 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 582 586 Example 1c: PPO Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231103 0222 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231103 022254 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 Security Health Plan 46 39045 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 35202 HL 3 2 23 0 PAT 19 NM1 QC 1 JONES JOY N3 4512 WEST AVENUE N4 EVANSVILLE AZ 863030000 DMG D8 19980820 F 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 48 1002 GE 1 000000001 IEA 1 000000001 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 583 586 Example 1d: Out of Network Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231103 0230 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231103 023056 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 Security Health Plan 46 39045 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 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_17 |
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 35202 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 582 586 Example 1c: PPO Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231103 0222 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231103 022254 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 Security Health Plan 46 39045 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 35202 HL 3 2 23 0 PAT 19 NM1 QC 1 JONES JOY N3 4512 WEST AVENUE N4 EVANSVILLE AZ 863030000 DMG D8 19980820 F 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 48 1002 GE 1 000000001 IEA 1 000000001 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 583 586 Example 1d: Out of Network Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231103 0230 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231103 023056 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 Security Health Plan 46 39045 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 35202 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, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 584 586 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 231103 0231 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231103 023133 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 Security Health Plan 46 39045 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 35202 HL 3 2 23 0 PAT 21 NM1 QC 1 MEXICO RON N3 32 BUFFALO RUN N4 ROCKING HORSE CA 99666 DMG D8 19480601 M REF Y4 32323232 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 43 557766 GE 1 000000001 IEA 1 000000001 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 585 586 1 30 25, 11:52 AM Security Health 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view security-health health-care-claim-institutional-x223a3 01H25JWH4ZF11XGRZE8AV514TR 586 586 | /kaggle/input/edi-db-835-837/Security Health 837 Health Care Claim_ Institutional.pdf | 2db701cea571a6ada086d11222f96bac | 2db701cea571a6ada086d11222f96bac_18 |
835 Companion Guide Refers to the lmplementation Guides Based on HIPM Transaction ASC Xl2N. Standards for Electronic Data lnterchange Technical Report Health Care Claim Advice (835) Xl2N 005010X221Al CarolinaCompleteHealth.com 1-833-552-3876 ТТУ: 711 (Hearing lmpaired para personas con problemas de audici6n) 10101 David Taylor Dr., Suite 300 Charlotte, NC 28262 2021 Carolina Complete Health. All rights reserved. July 2021 2 Preface Companion Guides (CG) to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Carolina Complete Health. 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 Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. Disclosure Statement The information provided here is for reference use only, and does not constitute the rendering of legal, financial, or any other professional advice or recommendations by Centene Corporation or Carolina Complete Health. CENTENE Corporation logo is a registered trademark and licensed for use by Centene Corporation and its operating subsidiaries. July 2021 3 Table of Contents.......................................................................................................................... 1. INTRODUCTION 4................................................................................................................................ 1.1 Scope 4......................................................................................................................... 1.2 Overview 4...................................................................................................................... 1.3 References 4...................................................................................................................... 2. GETTING STARTED 4....................................................................... 2.1 Working with Carolina Complete Health 4.......................................................................................... 2.2 Trading Partner Registration 4............................................................... 3. CONNECTIVITY WITH THE PAYER COMMUNICATIONS 5................................................................................ 3.1 System Availability and Downtime 5...................................................................... 3.2 Transmission Administrative Procedures 5........................................................................................... 3.3 Re-Transmission Procedure 5........................................................................................................... 4. CONTACT INFORMATION 5................................................................................................................. 4.1 EDI Assistance 5............................................................................................. 5. CONTROL SEGMENTS ENVELOPES 5............................................................................................................................. 5.1 ISA-IEA 5................................................................................................................................ 5.2 ST-SE 7.................................................................. 6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 7.............................................................................................. 7. TRADING PARTNER AGREEMENTS 7..................................................................................... 8. TRANSACTION SPECIFIC INFORMATION 7......................................................................................................................... 8.1 Loop N A 8..................................................................................................................... 8.2 Loop 1000B 8....................................................................................................................... 8.3 Loop 2100 8....................................................................................................................... 8.4 Loop 2110 9................................................................................................................................. 9. APPENDIX 10.......................................................................................................... 9.1 Change Summary 10 July 2021 4 1. INTRODUCTION 1.1 SCOPE This Companion Guide has been designed to describe to Carolina Complete Health s trading partners the format and data content of the Remittance Advice 835 transaction set in the Electronic Data Interchange (EDI) environment. The 835 transaction is used to report the status of a received claim. 1.2 OVERVIEW This Companion Guide has been written to assist you in implementing Health Care Claim Payment Advice transactions with Centene. 1.3 REFERENCES The document is a companion to the ASC X12N 835 (version 005010X221A1) Health Care Claim Payment Advice. 2. GETTING STARTED 2.1 WORKING WITH CAROLINA COMPLETE HEALTH Carolina Complete Health offers multiple connectivity options to receive The ASC X12N 835 (005010x221A1). All trading partners must have an active trading partner agreement. If a third- party has been selected to handle your electronic transactions additional Trading Partner information may be required. If you have additional question please contact us at our email address EDIBA Centene.com. 2.2 TRADING PARTNER REGISTRATION All trading partners or Providers who wish to receive the 835 Payment Advice from Carolina Complete Health are required to supply contact information along with submitter receiver information. To begin the process please contact Carolina Complete Health either via email at EDIBA Centene.com or you can call us at 1 (800) 225-2573, ext. 6075225. July 2021 5 3. CONNECTIVITY WITH THE PAYER COMMUNICATIONS 3.1 SYSTEM AVAILABILITY AND DOWNTIME The 835 transaction is generally available 24 hours a day, 7 days a week. To allow for maintenance, the 835 batch transactions may be unavailable every Thursday from 2pm - 9pm EST. All batch transactions are queued during this time frame and once maintenance is complete then batch files are released. 3.2 TRANSMISSION ADMINISTRATIVE PROCEDURES Carolina Complete Health only expects to receive a 999 if an 835 X12 rejects. The 999 should be received within 48 hours of receiving the 835 X12. 3.3 RE-TRANSMISSION PROCEDURE Carolina Complete Health will notify the Trading Partner when retransmitting the 835 files. 4. CONTACT INFORMATION 4.1 EDI Assistance Most questions can be answered by referencing this Companion Guide. If you have additional questions related to Carolina Complete Health s 835 Payment Advice, contact EDIBA centene.com 5. CONTROL SEGMENTS ENVELOPES 5.1 ISA-IEA This section describes the use of the Interchange Control segments, ISA and IEA. These segments mark the beginning and ending of an interchange. The ISA segment has a fixed length and all the elements within this segment must be populated. This segment includes a description of the expected sender and receiver codes and delimiters. The first element delimiter in the ISA segment is an Asterisk ( ) which will be used as the delimiter throughout the transaction. The final character in the ISA segment is a Tilde ( ) will be used as the delimiter for each segment in the transaction. July 2021 6 835: Segment ID Element ID Name Code Definition of Code Notes ISA ISA01 Authorization Information Qualifier '00' No Authorization Information Present ISA02 Authorization Information 10 'spaces' Authorization Information ISA03 Security Information Qualifier '00' Password Qualifier ISA04 Security Information 10 spaces Security Information ISA05 Interchange ID Qualifier of Sender Qualifier Decide Upon Enrollment ISA06 Interchange Sender ID Sender ID Interchange Sender ID ISA07 Interchange ID Qualifier of Receiver Qualifier Decide Upon Enrollment ISA08 Interchange Receiver ID Receiver Id Interchange Receiver ID ISA09 Interchange Date YYMMDD Date of the interchange ISA10 Interchange Time HHMM Time of the interchange ISA11 Interchange Control Standards Identifier '!' U.S. EDI Community of ASC X12, TDCC and UCS ISA12 Interchange Control Version Number '00501' ISA13 Interchange Control Number Must be identical to IEA02 ISA14 Acknowledgement Requested 0 No acknowledgement requested ISA15 Usage Indicator 'P' 'P': Production Data ISA16 Component Element Separator Component element separator is a delimiter and not a data element IEA Interchange Control Trailer Segment IEA01 Number of Included Functional Groups Functional Group count IEA02 Interchange Control Number Identical to ISA13 July 2021 7 5.2 ST-SE This section indicates the beginning and the ending of a transaction set and provides the count of the transmitted segments including the beginning (ST) and ending (SE) segments. These segments also provide a Transaction Set Control Number which must be identical in each segment. Segment ID Element ID Name Code Definition of Code Notes ST Transaction Set Header ST01 Transaction Set Identifier Code '835' ST02 Transaction Set Control Number Transaction Set Control Number. The transaction set control numbers in ST02 and SE02 must be identical. SE Transaction Set Trailer SE01 Transaction Segment Count Total Segments Total number of segments included in a transaction set including ST and SE segments. SE02 Transaction Set Control Number Transaction Set Control Number. The transaction set control numbers in ST02 and SE02 must be identical. 6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS Carolina Complete Health is CAQH CORE Phases I, II and III certified. 7. TRADING PARTNER AGREEMENTS Trading Partner Agreements for existing Partners are currently on file with Carolina Complete Health. For new Trading Partner requests please contact EDIBA centene.com. 8. TRANSACTION SPECIFIC INFORMATION (Loops) A Transaction Loop is a group of related segments. Carolina Complete Health specific values are required for the elements which comprise the segments for the 835 Transaction Loops. The following section identifies these loops, their segments and their element values: 8.1 Loop N A July 2021 8 8.2 Loop 1000B Payee Identification 8.3 Loop 2100 Claim Payment Information 8.4 Loop 2110 Service Payment Information 8.1 Loop N A (835) Loop Segment Name Definition of Code N A REF Receiver Identification Centene will provider this segment N A DTM Production Date Centene will provider this segment N A PLB Provider Adjustment Centene does not have a maximum limit of the PLB segments in a remittance 8.2 Loop 1000B (835) - Payee Identification Loop Segment Name Definition of Code 1000B N3 Payee Address Centene will always provide this segment 1000B REF Payee Additional Information Centene utilizes up to 4 occurrences in this segment 8.3 Loop 2100 (835)-Claim Payment Information Loop ID Segment Name Codes Notes Comments 2100 CLP02 Claim Status Code 1, 2, 3, 4 22 Future enhancements will be 19 20. 2100 NM1 Crossover Carrier Name Future enhancement will include this segment in unison with CLP02 19 and 20. 2100 NM1 Corrected Priority Payer Name Future enhancement will include this segment. 2100 NM1 Other Subscriber Name Future enhancement will include this segment 2100 REF01 Reference Identification Qualifier EA Other codes are not used 2100 REF01 Reference Identification Qualifier G2 Other codes are not used 2100 PER Claim Contact Information CX This segment is sent at the claim level July 2021 9 8.4 Loop 2110 (835)-Service Payment Information Loop ID Segment Name Codes Notes Comments 2110 REF01 Reference Line Item Control Number 6R Must Equal: 6R Provider Control Number (Line item control number in Loop 2400, REF01) Used in 837 Professional if submitted then this must be returned on the remittance. 2110 AMT01 Amount Qualifier Code B6 Other codes are not used PLB03-1, PLB03-2 Adjustment Reason Code, Provider Adjustment Identifier Most commonly used L6 WO 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. 10 9. APPENDIX 9.1 Change Summary The Change Log below will be used to document revisions that are made after initial publication of the Carolina Complete Health ANSI v5010 Companion Guide. 835 ERA Companion Guide Change Log Section Change Description Date of Change Version July 2021 | /kaggle/input/edi-db-835-837/CCH_835_Companion_Guide.pdf | ee743e3bec105809dc00507614737c96 | ee743e3bec105809dc00507614737c96_0 |
HIPAA Transaction Companion Guide 837 Professional Health Care Claim Refers to the Implementation Guides Based on X12 version 005010 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 complete Implementation Guide is derived from the 5010 version for use under the HIPAA regulation. Our version is referred in this document as the X12N 5010. 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 837 Professional Health Care Claims-X12-5010 Table of Contents 1 INTRODUCTION..............................................................................................................................................4 1.1 Overview 1.2 EDI Registration 1.3 NPI Implementation 1.4 Testing Prior to Production 2 CLAIMS PROCESSING................................................................................................................................5-6 2.1 Special Billing Situations 2.1.1 Service Lines 2.1.2 Coordination of Benefits 2.1.3 Sending Attachments or Paperwork to Support a Claim 2.1.4 Corrected Bills 2.2 Code Sets 2.3 Data Format Content 2.3.1 Dates 2.3.2 Decimals 2.3.3 Monetary Amounts,Unit Amounts, and Numeric Values 2.3.4 Phone Numbers 2.4 HIPAA Compliance Checking and Business Edits 2.5 Data Retention 2.6 Time Frames for Processing 2.7 Batch Volume 3 IDENTIFICATION CODES AND NUMBERS...................................................................................................7 3.1 Provider Identifiers 3.1.1 Providers in a Group Practice 3.1.2 Individual Providers Individually Paid Providers 3.2 Subscriber Identifiers 4 REPORTING...................................................................................................................................................8 4.1 Audit Report 5 DATA ELEMENT TABLE: PROFESSIONAL.............................................................................................9-13 5.1 837 Professional Health Care Claim - Header 5.1.1 837 Professional Health Care Claim - Submitter Receiver Details 5.2 837 Professional Health Care Claim - Detail 5.2.1 837 Detail: Information Source Provider Hierarchical Level 5.2.2 837 Detail: Subscriber Hierarchical Level 5.2.3 837 Detail: Patient Hierarchical Level 6 837 PROFESSIONAL HEALTH CARE CLAIM SAMPLE........................................................................14-16 6.1 Claim Scenario 6.2 837P NPI Claim Example ANSI X12 6.3 837P COB Claim Example ANSI X12 7 VERSION HISTORY.....................................................................................................................................17 8 FREQUENTLY ASKED QUESTIONS...........................................................................................................18 Page of SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 1 Introduction 1.1 Overview The purpose of this Companion Guide is to provide support for the submission of the HIPAA compliant 837 Professional claim and ensure the proper processing of claims submitted to SummaCare, Inc. This Companion Guide identifies unique information processing or adjudication needs specific to SummaCare, Inc in its implementation of the 837 Professional Health Care Claim transaction and should be used in conjunction with the HIPAA 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) 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. Electronics submission of claims will follow these guidelines: - Claims currently filed on CMS-1500 format will be sent as an 837P - Claims currently filed on ADA format will be sent as an 837D - Claims currently filed on UB-04 format will be sent as an 837I 1.2 EDI Registration As of May 23, 2007, any provider that submits claims using their National Provider ID (NPI) and Tax Identification Number (TIN) at the required levels specified in section five of this guide is not required to go through the registration process. 1.3 NPI Implementation Beginning October 1, 2010, SummaCare will reject claims that do not contain a NPI (at the Billing, Paid To or Rendering level). The lone exception for this will be provider submitting a claim with a valid taxonomy exception. We will reject a claim containing an invalid NPI number based on check digit validation. 1.4 Testing Prior to Production All Trading Partners must complete transaction testing prior to submission of transactions in production. This process is detailed separately in the Communication Companion Guide and on the SummaCare Website. Prior to submitting production claims electronically, all providers or their designated vendor must complete successful transaction testing. Providers must maintain a successful level of transaction submission to remain in production. Page of SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 Page of 2 Claims Processing 2.1 Special Billing Situations 2.1.1 Service Lines Any claim submitted that contains more than 97 service lines will be split into two claims by SummaCare for payment. 2.1.2 Coordination of Benefits When submitting an 837 transaction for members after billing their other insurance sources, the other payer s adjudication details that were provided on the 835 Remittance transaction must be supplied to SummaCare. The other payer s adjudication details, both at the line level and the claim level, are required to process the claim. Trading partners should review the Implementation Guides for the 837 HealthCare Claim transaction and the 835 HealthCare Claim Payment Advice transaction plus the crosswalks provided to fully understand the COB process. Reviewing section 1.4.5 of the 837 Implementation Guides will explain where to place the data within the 2320 loop. 2.1.3 Sending Attachments or Paperwork to Support a Claim SummaCare accepts supporting documentation by mail only. Illegible information will delay processing. All documentation and Attachment Cover Sheets must be received within 14 calendar days of the electronic transmission otherwise the claim will be denied. 2.1.4 Corrected Bills The Claim Frequency Type Code located in segment CLM05-03 determines the processing of corrected bills. - A corrected bill is indicated by placing a 7 in this field. 2.2 Code Sets When entering codes in an 837 Professional transaction,carefully follow the 837 Professional Implementation Guide (IG). Use HIPAA-Compliant codes from the current versions of the sources listed in the 837 Professional IG, Appendix C: External Code Sources - Only use standard CPT HCPCS Codes that are valid at the date of service. Currently use only ICD-10-CM diagnosis codes. No decimal point should be used for diagnosis codes. The decimal point is assumed. This is consistent with the specifications of the 837 Professional IG. - SummaCare will accept all HIPAA standard codes, however acceptance of these codes or modifiers will not alter the plan s covered benefits or current payment policies, guidelines or processes. 2.3 Data Format Content SummaCare accepts all compliant data elements on the 837 Professional Claim. Follow the points outlined below for consistent data format and content issues: SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 Page of 2.3.1 Dates All dates that are submitted on an incoming 837-claim transaction should be valid calendar dates in the appropriate format based on the respective qualifier. Future dates will be rejected. 2.3.2 Decimals Decimals should not be used in a diagnosis code. 2.3.3 Monetary Amounts,Unit Amounts, and Numeric Values The transaction will be rejected if the monetary amounts do not balance. SummaCare accepts monetary amounts only in US dollars. If codes related to foreign currencies are used, the claim will be denied. Unit amounts must be in whole numbers only. Negative values for monetary or unit amounts may not be processed and may result in the claim being rejected if submitted in the following segments, Loop 2300, Loop 2320 and Loop 2400: - CLM02 Monetary amount Total Submitted Changes - SV102 Monetary amount Line Item Charge Amount - SV104 Quantity Service Unit Count - AMT02 Monetary amount COB Payer Paid Amount - AMT02 Monetary amount COB Allowed Amount 2.3.4 Phone Numbers Telephone numbers should be presented as contiguous number strings. Do not use dashes or parenthesis markers. Area codes should always be used. 2.4 HIPAA Compliance Checking and Business Edits 997 Acknowledgement will be returned at the file level. The 997 will return a status reflecting accepted, rejected and accepted with error. 277CA will return a status reflecting each claim submitted in the 837 file. 2.5 Data Retention All claims data will be held for seven years. 2.6 Time Frames for Processing All claim files received by 7:00 PM EST will be processed the day received. Any claim files received after 7:00 PM EST will be processed the next business day. 2.7 Batch Volume There are no limits placed on volumes. SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 Page of 3 Identification Codes and Numbers 3.1 Provider Identifiers SummaCare requires all submitters to use one of the following combinations of identifiers until further notice: - Combination of the NPI or Taxonomy Exception with the TIN. Failure to use the correct number will result in the claim being rejected, denied or paid to the incorrect provider. 3.1.1 Providers in a Group Practice If you are a Rendering Provider in a Group Practice and your checks are issued to the Group Practice, please use your individual NPI number. If you use another provider s individual NPI number within the Group Practice, it will result in the check being issued correctly to the Group Practice, however, the Explanation of Payment (EOP) or the 835 Health Care Payment Advice will indicate the incorrect rendering provider. An example follows: Dr. Smith is part of Radiology Group. He uses the Tax Identification Number (TIN) of the group. If the 837 Health Care Claim Professional is submitted with the incorrect NPI, which is assigned to Dr. Jones in the same practice, the payment will be issued to the Radiology Group, but the EOP or 835 Health Care Payment Advice will list Dr. Jones as the rendering provider. 3.1.2 Individual Providers Individually Paid Providers If you are an individual provider or a provider in a Group Practice and your checks are issued to the individual physician, please use your individual NPI number. If you use another provider s individual NPI, the claim will be processed incorrectly. The EOP or 835 Health Care Payment Advice will be issued to the physician associated with the NPI that was submitted. An example follows: If Dr. Smith submits a claim using the NPI number assigned to Dr. Jones), the claim will be processed as submitted and the EOP or 835 Health Care Payment Advice will be returned to Dr. Jones along with the payment. 3.2 Subscriber Identifiers Submitters should be careful to use the member s identification number as it appears on their SummaCare member ID card. If the member s identification number is not submitted, the claim may be rejected or denied. Each member of the family is listed on the member identification card. Make sure the name of the patient is the same as the name on the identification card. SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 Page of 4 Reporting 4.1 Audit Report TA1 (Interchange Acknowledgement) When the HIPAA Compliant 837 claims file is submitted it is checked for ASC X12 syntax and HIPAA compliance errors. The TA1 report allows us to notify you of problems that were encountered in the interchange control structure. When the compliance check is completed, the TA1 (Interchange Acknowledgement) acknowledges that we have received or rejected an entire transmission. TA1 will be sent if your 837 file rejects or if the ISA14 (Sent in the 837 file) 1 997 When the HIPAA Compliant 837 claims file is submitted it is checked for ASC X12 syntax and HIPAA compliance errors. When the compliance check is complete, a 997 Acknowledgement will be sent to the Trading Partner informing them if the file has been accepted or rejected. If multiple transaction sets (ST-SE) are sent within a functional group (GS-GE), the entire functional group (GS-GE) will be rejected when an ASC X12 or HIPAA compliance error is found. 277CA Once the HIPAA Compliant 837 claims file is submitted into our claims processing system, a 277CA will be sent back to the Trading Partner (along with the 997) that submitted the claim file to us. The purpose of the 277CA Acknowledgement is to report the status of the interchange envelope for the 837 transaction that you submitted. This acknowledgement can either be accepted or rejected depending on whether the envelope was accepted or rejected. An accepted acknowledgement occurs when the envelope is set up correctly. A rejected acknowledgement occurs when the envelope is set up incorrectly or the information in the envelope does not match the information that is contained within our claims processing system. The 277CA will advise you of accepted and rejected claims. Review the rejected claims, correct the errors, and resubmit as a corrected claim file. Rejected claims associated with this transaction will not be processed and therefore will not be considered for payment Both the 277CA and 997 will be sent the day following the receipt of the 837 Professional Health Care Claim file. SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 Page of 5 Data Element Table: Professional After the claim transmissions have passed Implementation Guide compliance checks for acceptance into the SummaCare system, business edits, specific to SummaCare, are then applied to the incoming HIPAA compliant claims. The business edits include security validation and the verification of proprietary business requirements. The following 837 Professional Health Care Claim Detail Data Element Table contain only data elements that require instructions to efficiently enhance the claims processing through SummaCare systems. If a data element does not need specific information for SummaCare processing, then it is not documented in this Data Element Table. Use this table in conjunction with the ASC X12N 837 Implementation Guide (837 IG) for Professional Claims. All alpha characters should be formatted as UPPERCASE only. 5.1 837 Professional Health Care Claim - Header The 837 Header identifies the start of a transaction, the specific transaction set, and the transaction s business purpose. Also, when a transaction set uses a hierarchical data structure, a data element in the header, BHT01 (Hierarchical Structure Code) relates the type of business data expected within each level. The BHT - Beginning of Hierarchical Transaction is required. - BHT01 Hierarchical Structure Code - BHT02 Transaction Set Purpose Code - BHT03 Reference Identification - BHT04 Date of Transaction - BHT05 Time of Transaction - BHT06 Transaction Type Code 5.1.1 837 Professional Health Care Claim - Submitter Receiver Details Loop 1000A 1000B contains Submitter and Receiver information. SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 Envelope Section Label Segment Description Value Options for SummaCare Description Comments Individual or Organizational Name NM109 Identification Code Sender Submitter Identifier Enter the EDI Sender ID assign to you by SummaCare. This Sender ID should be identical to the value in ISA06 and GS02. Individual or Organizational Name NM103 Last Name or Organization Name SummaCare Represents the Receiver Name as SummaCare Individual or Organizational Name NM109 Identification Code 95202 The Receiver Primary Identifier (SummaCare Payer Identification Number) Page of SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 5.2 837 Professional Health Care Claim - Detail The 837 Detail level has a hierarchical level (HL) structure based on the participants involved in the transaction. The three levels for the participant types include: - Information Source (Billing Provider) - Subscriber (can be the Patient when the Subscriber is the Patient) - Dependent (when the Patient is not the Subscriber) 5.2.1 837 Detail: Information Source Provider Hierarchical Level The first hierarchical level (HL) of the 837 details is the Information Source HL, also known as the Billing Pay-To Provider HL. Envelope Section Label Segment Description Value Options for SummaCare Description Comments Provider Information PRV01 Provider Code BI BI - Billing Provider Currency CUR02 Currency Code USD or "Blank" USD - US Dollars SummaCare recognizes monetary amounts as US dollars only. Billing Provider Name NM108 Identification Code Qualifier XX XX National Provider ID (NPI) Billing Provider Name NM109 Identification Code NPI number The Billing Provider s NPI Number. Only send the 9 digit TAX Identification Number Please do not send dashes or leading zeroes Billing Provider Secondary Identification REF01 Reference Identification Qualifier EI Employer s Identification Number Billing Provider Secondary Identification REF02 Reference Identification Billing Provider s Employer s Identification Number The Employer s Identification Number must be sent when the provider s NPI is sent in the NM108 NM109 segment. Only send the 9 digit TAX Identification Number Please do not send dashes or leading zeroes 5.2.2 837 Detail: Subscriber Hierarchical Level The second hierarchical level (HL) of the 837 details is the Subscriber HL. SummaCare encourages our Trading Partners to submit one claim per transaction set (ST-SE) to eliminate the impact of errors on other clean claims within the same interchange; our X12 and HIPAA compliance edits will reject the entire transaction set if an error is found. Envelope Section Label Segment Description Value Options for SummaCare Description Comments Subscriber Information SBR01 Payer Responsibility Sequence Number Code P, S, T P - Primary S - Secondary T - Tertiary Usage of 'S' or 'T' requires that information be populated in loop 2320. This will give us the other payer's information. Subscriber Information SBR02 Individual Relationship Code 18 18 - Self Subscriber Information SBR03 Reference Identification Contract Holder's Member ID Number Enter the ID number exactly as it appears on the front of the contract holder's ID card, including the two-digit suffix. Individual or Organization Name NM108 Identification Code Qualifier MI Member Identification Number Individual or Organization Name NM109 Identification Code Patient's Member ID Number Enter the ID number exactly as it appears on the front of the contract holder's ID card, including the two-digit suffix. Page of SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 5.2.3 837 Detail: Patient Hierarchical Level The third hierarchical level (HL) of the 837 detail is the Patient HL. SummaCare encourages our Trading Partners to submit one claim per transaction set (ST-SE) to eliminate the impact of errors on other clean claims within the same interchange; our X12 and HIPAA compliance edits will reject the entire transaction set if an error is found. Envelope Section Label Segment Description Value Options for SummaCare Description Comments Claim Information CLM01 Patient Control Number Provider's Patient Account Number As indicated in the IG, SummaCare supports a maximum of 20 characters in this data element. This number is echoed back to the Submitter in the 835 and other transactions. Claim Information CLM02 Monetary Amount Total Claim Charge Amount This field must equal the total amount of submitted charges in Loop 2400, SV102. Claim Supplemental Information PWK02 Report Transmission Code BM SummaCare accepts supporting documentation by mail only. All documentation and Attachment Cover Sheets must be received within 14 calendar days of the electronic transmission otherwise the claim will be denied. Note-Illegible information will delay processing. Claim Supplemental Information PWK05 Identification Code AC Attachment Control Number Claim Supplemental Information PWK06 Identification Code Self-Assigned This Field is reserved for a unique self-assigned attachment Control Number Claim Identifier Number for Transmission Intermediaries REF01 Reference Identification Qualifier D9 Unique number assigned by the clearinghouse submitter of claims Claim Identifier Number for Transmission Intermediaries REF02 Reference Identification Self-Assigned Clearinghouse Trace Number. The value carried in this element is limited to a maximum of 20 positions. Claim Note NTE01 Note Reference Code ADD General claim notes remarks must be submitted with this qualifier Claim Note NTE02 Description Claim Note Text Claim Notes Remarks Individual or Organizational Name NM101 Entity Identifier Code 82 82 - Rendering Provider If this segment is submitted, then the REF01 and REF02 segments with the specified data requested must also be submitted. Failure to submit the combination of these segments will result in the claim being rejected. Individual or Organizational Name NM102 Entity Type Qualifier 1, 2 1 - Person 2 - Non-Person Entity Individual or Organizational Name NM103 Last Name or Organization Name Rendering Provider's Last Name or Name of the Organization Represents the Rendering Provider's Last Name or Name of the Organization Individual or Organizational Name NM104 First Name Rendering Provider's First Name Represents the Rendering Provider's First Name Page of SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 Envelope Section Label Segment Description Value Options for SummaCare Description Comments Individual or Organizational Name NM108 Identification Code Qualifier XX National Provider ID (NPI) Individual or Organizational Name NM109 Identification Code NPI number Enter the Rendering Provider s NPI Number. Please do not send dashes or leading zeroes Rendering Provider Secondary Identification REF01 Reference Identification Qualifier EI Employer s Identification Number Rendering Provider Secondary Identification REF02 Reference Identification Qualifier Rendering Provider s Employer s Identification Number The Employer s Identification Number must be sent when the provider s NPI is sent in the NM108 NM109 segment. Only send the 9 digit tax identification number Please do not send dashes or leading zeroes Individual or Organizational Name NM101 Entity Identifier Code 77 77 Service Facility This is Required for all Professional claims when the location code is NOT one of the following - ( 03, 11, 12, 41, 42, 81, 20, 60, 71, 49, 65, 72 ) Failure to submit this segment will result in the claim being rejected. Individual or Organizational Name NM102 Entity Type Qualifier 2 Non-Person Entity Individual or Organizational Name NM103 Last Name or Organization Name Last Name or Organization Name Service Facility Location Name Individual or Organizational Name NM108 Identification Code Qualifier XX National Provider ID (NPI) Individual or Organizational Name NM109 Identification Code NPI Number Enter the Service Facility s NPI Number. Please do not send dashes or leading zeroes Party Location N301 Address Information Facility Address This is Required for all Professional claims when the location code is NOT one of the following - ( 03, 11, 12, 41, 42, 81, 20, 60, 71, 49, 65, 72 ) Failure to submit this segment will result in the claim being rejected. Geographic Location N401 City Name Facility City Name This is Required for all Professional claims when the location code is NOT one of the following - ( 03, 11, 12, 41, 42, 81, 20, 60, 71, 49, 65, 72 ) Failure to submit this segment will result in the claim being rejected. Geographic Location N402 State Facility Location State This is Required for all Professional claims when the location code is NOT one of the following - ( 03, 11, 12, 41, 42, 81, 20, 60, 71, 49, 65, 72 ) Failure to submit this segment will result in the claim being rejected. Geographic Location N403 Postal Code Facility Location Postal Code This is Required for all Professional claims when the location code is NOT one of the following - ( 03, 11, 12, 41, 42, 81, 20, 60, 71, 49, 65, 72 ) Failure to submit this segment will result in the claim being rejected. Page of SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 Envelope Section Label Segment Description Value Options for SummaCare Description Comments Other Subscriber Information SBR01 Payer Responsibility Sequence Number Code P - Primary S - Secondary T - Tertiary See complete list on Implementation Guide Usage of 'S' requires that 'P' be present Usage of 'T' requires that both 'P' and 'S' be present Other Payer Name NM108 Amount Qualifier Code FI Submitters are required to send all known information on other payers in Loop ID-2330 Other Payer Name NM109 Other Payer Primary Self-Assigned This number must be identical to SVD01 (Loop 2430) for COB. If COB submitted, NM109 is required and must be unique from any other 2330B NM109 value. Service Line Number LX01 Assigned Number Service Line LX segment must begin with 1 and increase in increments of 1 for each additional service line on the claim Any claim submitted that contains more than 97 service lines will be split into to two claims by SUMMACARE for payment. Professional Services SV101-3 Procedure Modifier Procedure Modifier 1 SUMMACARE considers the modifiers listed in the CPT and HCPCS manuals to be compliant. An anesthesia modifier must be used with any anesthesia service to correctly identify the service as anesthesia. Professional Services SV101-4 Procedure Modifier Procedure Modifier 2 SUMMACARE considers the modifiers listed in the CPT and HCPCS manuals to be compliant. An anesthesia modifier must be used with any anesthesia service to correctly identify the service as anesthesia. Professional Services SV101-5 Procedure Modifier Procedure Modifier 3 SUMMACARE considers the modifiers listed in the CPT and HCPCS manuals to be compliant. An anesthesia modifier must be used with any anesthesia service to correctly identify the service as anesthesia. Professional Services SV101-6 Procedure Modifier Procedure Modifier 4 SUMMACARE considers the modifiers listed in the CPT and HCPCS manuals to be compliant. An anesthesia modifier must be used with any anesthesia service to correctly identify the service as anesthesia. Professional Services SV102 Monetary Amount (Line Item Charge Amount) The sum of the service lines charges reported in this field must be equal to the Total Claim Charge Amount in Loop 2300 CLM02 Professional Services SV103 Units or Basis for Measurement Code MJ, UN MJ - Minutes (Required for Anesthesia Claims) UN - Units Professional Services SV104 Quantity Service Unit Minute Count SUMMACARE accepts values greater than or equal to 1. The service unit count may not exceed 999. If the quantity exceeds 999 the claim will be rejected. Line Adjudication Info SVD01 Identification Code Other Payer Identifier Value is required when segment sent and must match a previous 2330B NM109 value Page of SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 6 837 Professional Health Care Claim Sample 6.1 Claim Scenario SummaCare member, Johnny Doe, went to his PCP, Dr. Joel Smith at Smith s Family Practice, on September 15, 2022. Dr. Smith submitted the claim to a clearinghouse. The clearinghouse transmitted the claim to SummaCare in the 837P file format. Claim Information: Claim Date: 7 17 2022 Claim Time: 9:39 am Sender: Clearinghouse Sender Electronic Transmitter ID: Type 46, 999999999 Receiver: SummaCare Receiver Electronic Transmitter ID: Type 46 - 95202 Professional Claim: 005010X222 Billing Provider: Smiths Family Practice Tax Identification Number: Type XX (NPI), 1234567890 Provider Address: 123 Med Center Drive Akron, OH 44308 Provider Contact Information: Smiths Family Practice Phone (330) 555-5555 Subscriber: Jonathan Doe Subscriber ID: 98765432100 Group: V99999 Birth date: 4 5 74 Sex: M Insurance Payer ID: SummaCare, 95202 Patient: Johnny Doe Patient ID: 98765432102 Patient Address: 100 Patient RD Akron, OH 44308 Date of Birth: 10 28 02 Sex: M Provider s Patient Account Number at Claim level: 0027833 Clearinghouse Claim Reference Number: Type D9, 01234567890 Diagnosis: ICD-10, R509 - Fever Rendering Provider at Claim level: Dr. Joel C. Smith, DO Rendering Provider ID at Claim level: Type 24 (TIN), 34-1131413 Service Procedure CPT: 99212 0ffice visit, unfocused, 15 minutes Charged Amount: 50.00 Units: 1 Date of Service: 07 15 22 Page of SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 6.2 837P NPI Claim Example ANSI X12 ST 837 000000001 005010X222 BHT 0019 00 000000001 20220715 0939 CH NM1 41 2 CLEARINGHOUSE 46 999999999 PER IC CLEARINGHOUSE TE 8005555555 NM1 40 2 SUMMACARE 46 95202 HL 1 20 1 NM1 85 2 SMITHS FAMILY PRACTICE XX 1234567890 N3 123 MED CENTER DRIVE N4 AKRON OH 44308 REF EI 111223333 PER IC SMITHS FAMILY PRACTICE TE 3305555555 HL 2 1 22 1 SBR P V99999 CI NM1 IL 1 DOE JONATHAN MI 98765432100 DMG D8 19740405 M NM1 PR 2 SUMMACARE PI 95202 HL 3 2 23 0 PAT 19 NM1 QC 1 DOE JOHNNY MI 98765432102 N3 100 PATIENT RD N4 AKRON OH 44308 DMG D8 20021028 M CLM 0027833 50 22::1 Y A Y Y C REF D9 01234567890 HI ABK:R509 NM1 82 1 SMITH JOEL C DO XX 9876543210 REF EI 44455666 NM1 77 2 SUMMA HEALTH SYSTEMS XX 1234567890 N3 123 SUMMA DRIVE N4 AKRON OH 44308 LX 1 SV1 HC:34196 50 UN 1 1 DTP 472 D8 20220715 SE 35 000000001 Page of SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 6.3 837P COB Claim Example ANSI X12 ST 837 0001 005010X222 BHT 0019 00 1 20220715 08280000 CH NM1 41 2 SUGARHILL BILLING SERVICE 46 00123 PER IC TECHNOLOGY SUPPORT CENTER TE 3305554321 NM1 40 2 MULBERRY HEALTH SYSTEM 46 441XX234 HL 1 20 1 NM1 85 2 JACK SPRAT INC XX 300300123 N3 PO BOX 1687 N4 FOREST HILL OH 441234107 REF 1C 0123456789 PER IC BARBIE TE 2165552020 HL 2 1 22 0 SBR S 18 731062 ZZ NM1 IL 1 GREEN MARY MI 98799432100 N3 1506 MAGIC DR N4 AKRON OH 44308 DMG D8 19220101 F REF IG 012345678D NM1 PR 2 ABC HEALTH PLAN PI 44123C123 N3 17 TECHNOLOGY N4 COLUMBIA SC 29219 CLM TV12345678987654 59.28 12::1 Y A Y Y C REF F5 N HI ABK:R509 NM1 82 2 LINUS INC XX 300300123 REF 1C 0123456789 SBR P 18 MB MB AMT D 24.46 AMT AAE 30.57 AMT B6 30.57 DMG D8 19220101 F OI Y C Y NM1 IL 1 GREEN MARY MI 270123456D N3 1506 MAGIC DR N4 AKRON OH 443081234 NM1 PR 2 XYZ HEALTH PLAN, INC PI 00123 PER IC COORDINATION OF BENEFITS TE 8885551105 FX 8885550008 REF F8 0123456789000 NM1 82 2 REF 1C 1234567890 LX 1 SV1 HC:E0434:RR 59.28 UN 1 12 1 DTP 472 D8 20220715 AMT AAE 30.57 NM1 DK 1 JOHNSON DAVID N3 2400 MONTY RD N4 NORFOLK VA 245510687 REF 1G B01234 SVD 00123 24.46 HC:E0434:RR 1 CAS CO 96 28.71 CAS PR 2 6.11 DTP 573 D8 20220715 SE 54 0001 GE 1 1 IEA 1 000000001 SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 Page of 7 Version History The following Version History is provided to easily identify updates from the last version of this Companion Guide. Version Date Updated Update 1.0 August 2017 Loop 2310C 77 Service Facility Service Facility Address This is Required for all Professional claims when the location code is NOT one of the following -( 03, 11, 12, 41, 42, 81, 20, 60, 71, 49, 65, 72 ). Failure to submit this segment will result in the claim being rejected. 1.1 February 2024 Update: - Any claim submitted that contains more than 97 Service Lines (was 85 Service Lines) will be split into to two claims by SUMMACARE for payment (LX01) - 5.1 837 Professional Health Care Claim - Header Section - Updated Questions 2 and 6 - Removed Question 7 Added: - 5.1.1 837 Professional Health Care Claim - Submitter Receiver Details Section - New Question 7 SummaCare Companion Guide 837 Professional Health Care Claims-X12-5010 Page of 7 Frequently Asked Questions 1. What is Electronic Data Interchange? Electronic Data Interchange (EDI) is the computer-to-computer exchange of business documents in a standard electronic format between business Partners. By moving from a paper-based exchange of business document to one that is electronic, businesses enjoy major benefits such as reduced cost, increased processing speed, reduced errors and improved relationships with business Partners. 2. How many claims do you currently receive electronically? Approximately 98 of our claims today are received electronically. 3. Why submit claims electronically? Electronic claims are not subject to postal delays and may be transmitted 24 hours a day seven days a week. Submitting electronically reduces costs, increases processing speeds and reduces errors. 4. Will SummaCare reject claims submitted electronically without the NPI number? Yes, unless the claim is sent with a Taxonomy Exception. 5. Do you accept secondary claims electronically? Yes, we accept secondary claims electronically. However, the Explanation of Benefits information is required. It should be sent with the claim electronically, detailing the COB information at the line level. 6. Which claims may be submitted electronically? We accept all claims electronically. However, SummaCare only accepts supporting documentation by mail. All documentation and attachment cover sheets must be received within 14 calendar days of the electronic claim being transmitted, otherwise the claim will be denied. Note: Illegible information will delay processing of that claim. 7. Can Participating Provider receive Paper Remits (EOP)? No, all Participating Providers that submit claims electronically, will be asked to review their Remits through their Plan Central Account or have their Remits sent to a Clearing House of their choice. Providers can register for a Plan Central Account using the below link and then clicking on 'Request Access for the Portal'. https: www.summacare.com providers | /kaggle/input/edi-db-835-837/HIPAA SummaCare 837 5010 Professional Companion Guide.pdf | 44f170a94241bf9ecc0be958dfd4ed75 | 44f170a94241bf9ecc0be958dfd4ed75_0 |
Companion Guide 835 Remittance Advice Transaction Health Care Claim Payment Advice 835 Payer Sheet January 2011 Companion Guide 835 Remittance Advice Transaction Revision Date: January 2011 Version: 3.0 Page 2-2 Table of Contents Section 1: Revision History.................................................................................... 2-3 Section 2: Health Care Claim Payment Advice................................................... 2-4 Overview......................................................................................................... 2-4 Segment Usage 835...................................................................................... 2-4 Segment and Data Element Description.......................................................... 2-7 Header.............................................................................................................. 2-8 ST - Transaction Set Header........................................................................ 2-8 BPR Financial Information....................................................................... 2-8 TRN: Reassociation Trace Number........................................................... 2-10 REF: Receiver Identification..................................................................... 2-10 DTM: Production Date.............................................................................. 2-10 N1: Payer Identification............................................................................ 2-11 N3: Payer Address..................................................................................... 2-11 N4: Payer City, State, ZIP Code................................................................ 2-11 PER: Payer Business Contact Information................................................ 2-11 PER: Payer Technical Contact Information.............................................. 2-11 N1: Payee Identification............................................................................ 2-12 N3: Payee Address.................................................................................... 2-12 N4: Payee City, State, ZIP Code............................................................... 2-12 REF: Payee Additional Identification........................................................ 2-12 Detail............................................................................................................. 2-13 LX: Header Number.................................................................................. 2-13 CLP: Claim Payment Information............................................................. 2-13 CAS: Claim Adjustment............................................................................ 2-13 NM1: Patient Name................................................................................... 2-13 NM1: Corrected Patient Insured Name................................................... 2-13 NM1: Service Provider Name................................................................... 2-14 NM1: Corrected Priority Payer Name....................................................... 2-14 NM1: Other Subscriber Name................................................................... 2-14 MIA: INPATIENT ADJUDICATION INFORMATION......................... 2-14 MOA: Outpatient Adjudication Information............................................. 2-14 REF: Other Claim Related Identification.................................................. 2-15 REF: Rendering Provider Identification.................................................... 2-15 DTM: Statement From or To Date............................................................ 2-15 DTM: Coverage Expiration Date.............................................................. 2-15 SVC: Service Payment Information.......................................................... 2-15 DTM: Service Date................................................................................... 2-16 CAS: Service Adjustment......................................................................... 2-16 REF: Service Identification....................................................................... 2-16 REF: Line Item Control Number............................................................... 2-16 REF: Rendering Provider Information...................................................... 2-16 LQ: Health Care Remark Codes................................................................ 2-17 Summary........................................................................................................ 2-17 PLB: Provider Adjustment........................................................................ 2-17 SE: Transaction Set Trailer....................................................................... 2-17 Revision Date: January 2011 Version: 3.0 Page 2-3 Section 1: Revision History Document Version Number Revision Date Revision Page Number(s) Reason for Revisions Revisions Completed By Version 1.0 ISDH HIPAA Version 2.1 ISDH HIPAA Version 3.0 January 2011 All 5010 Implementation ISDH HIPAA Companion Guide 835 Remittance Advice Transaction Revision Date: January 2011 Version: 3.0 Page 2-4 Section 2: Health Care Claim Payment Advice Overview The ASC X12N 835 (005010X221A1) is the HIPAA-mandated transaction for sending an Electronic Remittance Advice (ERA) to providers. It is highly recommended that implementers have the following resources available during the development process: This document, Companion Guide 835 Health Care Claim Remittance Advice ASC X12N 835 (005010X221A1) Segment Usage 835 The following matrix lists all segments available for creation with the 5010 version of the 835 Health Care Claim Payment Advice IG. The guide includes a Usage column that identifies segments that are required, situational, or not used by ISDH. A required segment element appears for all transactions. A situational segment is not required for each type of transaction; however, a situational segment may be required under certain circumstances. Any data in a segment identified in the Usage column with an X is never sent by the ISDH. Any segment identified in the Usage column as required or situational by the IG, and the ISDH, is explained in detail in this section of the companion guide. Table 1.1 835 Segments Segment ID Loop ID Segment Name ISDH Usage R Required S Situational X Not Used ST N A Transaction Set Header R BPR N A Financial Information R TRN N A Reassociation Trace Number R CUR N A Foreign Currency Information X REF N A Receiver Identification S REF N A Version Identification X DTM N A Production Date S Revision Date: January 2011 Version: 3.0 Page 2-5 Segment ID Loop ID Segment Name ISDH Usage R Required S Situational X Not Used N1 1000A Payer Identification R N3 1000A Payer Address R N4 1000A Payer, City, State, ZIP, Code R REF 1000A Additional Payer Identification X PER 1000A Payer Business Contact Information S PER01 1000A Payer Technical Contact Information R PER01 1000A Payer WEB Site X N1 1000B Payee Identification R N3 1000B Payee Address S N4 1000B Payee City, State, ZIP Code R REF 1000B Payee Additional Identification S RDM 1000B Remittance Delivery Method X LX 2000 Header Number S TS3 2000 Provider Summary Information X TS2 2000 Provider Supplemental Summary Information X CLP 2100 Claim Payment Information R CAS 2100 Claim Adjustment S NM1 2100 Patient Name R NM1 2100 Insured Name X NM1 2100 Corrected Patient Insured Name S NM1 2100 Service Provider Name S Companion Guide 835 Remittance Advice Transaction Revision Date: January 2011 Version: 3.0 Page 2-6 Segment ID Loop ID Segment Name ISDH Usage R Required S Situational X Not Used NM1 2100 Crossover Carrier Name X NM1 2100 Corrected Priority Payer Name S NM1 2100 Other Subscriber Name S MIA 2100 Inpatient Adjudication Information S MOA 2100 Outpatient Adjudication Information S REF 2100 Other Claim Related Identification S REF 2100 Rendering Provider Identification S DTM 2100 Statement From or To Date S DTM 2100 Coverage Expiration Date S DTM 2100 Claim Received Date X PER 2100 Claim Contact Information X AMT 2100 Claim Supplemental Information X QTY 2100 Claim Supplemental Information Quantity X SVC 2110 Service Payment Information S DTM 2110 Service Date S CAS 2110 Service Adjustment S REF 2110 Service Identification S REF 2110 Line Item Control Number S Revision Date: January 2011 Version: 3.0 Page 2-7 Segment ID Loop ID Segment Name ISDH Usage R Required S Situational X Not Used REF 2110 Rendering Provider Information S REF 2110 Healthcare Policy Identification X AMT 2110 Service Supplemental Amount X QTY 2110 Service Supplemental Quantity X LQ 2110 Health Care Remark Codes S PLB N A Provider Adjustment S SE N A Transaction Set Trailer R Segment and Data Element Description This section contains a table representing any segment that is required or situational for the Indiana HIPAA implementation of the 835. Each segment table contains rows and columns describing different elements of the segment. If a segment is not used by ISDH, the table for that segment will not be shown. Segment Name The industry assigned segment name as identified in the IG. Segment ID The industry assigned segment ID as identified in the IG. Loop ID The loop where the segment should appear. Usage Identifies the segment as required or situational. Segment Notes A brief description of the purpose or use of the segment including ISDH-specific usage. Example An example of complete segment. Element ID The industry assigned segment ID as identified in the IG. Usage Identifies the data element as R-required, S-situational, or N A-not used. Guide Description Valid Values Industry name associated with the data element. If no industry name exists, this is the IG data element name. This column also lists in BOLD the values and or code set to use. Comments Description of the contents of the data elements, including field length. Companion Guide 835 Remittance Advice Transaction Revision Date: January 2011 Version: 3.0 Page 2-8 Header Segment Name ST - Transaction Set Header Segment ID ST Loop ID N A Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name BPR Financial Information Segment ID BPR Loop ID N A Usage Required Segment Notes See ISDH specific rules below. Element ID Usage Guide Description and Valid Values Comment BPR01 R Transaction handling code I Remittance information only H Notification only I This code is issued for fee-for- service claims. H This code is issued to pass information only without any reference to payment. BPR02 R Total actual provider payment amount BPR03 R Credit or debit flag code C Credit BPR04 R Payment method code ACH Automated Clearing House CHK Check NON Non-Payment Data ACH This code is issued when money is moved electronically through the ACH, or to notify the provider that an ACH transfer was requested. When this code is used, information in BPR05 through BPR15 must also be included. CHK This code is issued when BPR01 contains I and indicates a check was issued for payment. NON This code is issued when the Transaction Handling Code (BPR01) is H, indicating that this is information only and no dollars are to Revision Date: January 2011 Version: 3.0 Page 2-9 Element ID Usage Guide Description and Valid Values Comment be moved. BPR05 S Payment format code CCP Cash Concentration Disbursement plus Addenda (CCD ) (ACH) Required when BPR04 is ACH BPR06 S Depository financial institution (DFI) identification number qualifier 01 ABA transit routing number including check digits (9) Required when BPR04 is ACH, BOP or FWT. BPR07 S Sender DFI identifier This element contains the identifying number of the financial institution and is issued when BPR04 contains ACH; otherwise, the data element will not be returned. If used, the number is 074000065. BPR08 S Account number qualifier DA Demand deposit Required when BPR04 is ACH BPR09 S Sender Bank Account Number Required when BPR04 is ACH BPR10 S Payer identifier Federal tax ID number 1356000158 Required when BPR04 is ACH BPR11 S Originating company supplemental code Not used by ISDH BPR12 S Depository financial institution (DFI) identification number qualifier. 01 ABA transit routing number including check digits (9 digits) Required when BPR04 is ACH BPR13 S Receiver or provider bank ID number Required when BPR04 is ACH BPR14 S Account number qualifier DA Demand deposit Required when BPR04 is ACH BPR15 S Receiver or provider account number Required when BPR04 is ACH BPR16 R Check issue or EFT effective date in CCYYMMDD format. BPR17 N A Business function code Not used BPR18 N A DFI ID number qualifier Not used BPR19 N A DFI identification number Not used BPR20 N A Account number qualifier Not used BPR21 N A Account number Not used Companion Guide 835 Remittance Advice Transaction Revision Date: January 2011 Version: 3.0 Page 2-10 Segment Name TRN: Reassociation Trace Number Segment ID TRN Loop ID N A Usage Required Segment Notes This segment uniquely identifies this transaction. Example TRN 1 71700666555 1356000158 Element ID Usage Guide Description and Valid Values Comments TRN01 R Trace type code 1 Current transaction trace numbers Identifies the transaction being referenced. TRN02 R Check or EFT trace number If no payment is made, the text NO PAY and a date and time stamp are used instead. TRN03 R Payer identifier Federal tax ID number 1356000158 This is the ISDH federal tax ID number and is always preceded by 1. It is identical to BPR10. TRN04 S Originating company supplemental code Not used by ISDH Segment Name REF: Receiver Identification Segment ID REF Loop ID N A Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name DTM: Production Date Segment ID DTM Loop ID N A Usage Situational Segment Notes Follow the HIPAA and IG rules. Revision Date: January 2011 Version: 3.0 Page 2-11 Segment Name N1: Payer Identification Segment ID N1 Loop ID 1000A Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name N3: Payer Address Segment ID N3 Loop ID 1000A Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name N4: Payer City, State, ZIP Code Segment ID N4 Loop ID 1000A Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name PER: Payer Business Contact Information Segment ID PER01 Loop ID 1000A Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name PER: Payer Technical Contact Information Segment ID PER01 Loop ID 1000A Usage Required Segment Notes Follow the HIPAA and IG rules. Companion Guide 835 Remittance Advice Transaction Revision Date: January 2011 Version: 3.0 Page 2-12 Segment Name N1: Payee Identification Segment ID N1 Loop ID 1000B Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name N3: Payee Address Segment ID N3 Loop ID 1000B Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name N4: Payee City, State, ZIP Code Segment ID N4 Loop ID 1000B Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name REF: Payee Additional Identification Segment ID REF Loop ID 1000B Usage Situational Segment Notes Follow the HIPAA and IG rules. Revision Date: January 2011 Version: 3.0 Page 2-13 Detail Segment Name LX: Header Number Segment ID LX Loop ID 2000 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name CLP: Claim Payment Information Segment ID CLP Loop ID 2100 Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name CAS: Claim Adjustment Segment ID CAS Loop ID 2100 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name NM1: Patient Name Segment ID NM1 Loop ID 2100 Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name NM1: Corrected Patient Insured Name Segment ID NM1 Loop ID 2100 Usage Situational Segment Notes Follow the HIPAA and IG rules. Companion Guide 835 Remittance Advice Transaction Revision Date: January 2011 Version: 3.0 Page 2-14 Segment Name NM1: Service Provider Name Segment ID NM1 Loop ID 2100 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name NM1: Corrected Priority Payer Name Segment ID NM1 Loop ID 2100 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name NM1: Other Subscriber Name Segment ID NM1 Loop ID 2100 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name MIA: INPATIENT ADJUDICATION INFORMATION Segment ID MIA Loop ID 2100 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name MOA: Outpatient Adjudication Information Segment ID MOA Loop ID 2100 Usage Situational Segment Notes Follow the HIPAA and IG rules. Revision Date: January 2011 Version: 3.0 Page 2-15 Segment Name REF: Other Claim Related Identification Segment ID REF Loop ID 2100 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name REF: Rendering Provider Identification Segment ID REF Loop ID 2100 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name DTM: Statement From or To Date Segment ID DTM Loop ID 2100 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name DTM: Coverage Expiration Date Segment ID DTM Loop ID 2100 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name SVC: Service Payment Information Segment ID SVC Loop ID 2110 Usage Situational Segment Notes Follow the HIPAA and IG rules. Companion Guide 835 Remittance Advice Transaction Revision Date: January 2011 Version: 3.0 Page 2-16 Segment Name DTM: Service Date Segment ID DTM Loop ID 2110 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name CAS: Service Adjustment Segment ID CAS Loop ID 2110 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name REF: Service Identification Segment ID REF Loop ID 2110 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name REF: Line Item Control Number Segment ID REF Loop ID 2110 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name REF: Rendering Provider Information Segment ID REF Loop ID 2110 Usage Situational Segment Notes Follow the HIPAA and IG rules. Revision Date: January 2011 Version: 3.0 Page 2-17 Segment Name LQ: Health Care Remark Codes Segment ID LQ Loop ID 2110 Usage Situational Segment Notes Follow the HIPAA and IG rules. Summary Segment Name PLB: Provider Adjustment Segment ID PLB Loop ID N A Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name SE: Transaction Set Trailer Segment ID SE Loop ID N A Usage Required Segment Notes Follow the HIPAA and IG rules. | /kaggle/input/edi-db-835-837/ISDH_Companion_Guide_835_5010.pdf | 6ae1b89785f291ca74f2aad9b1178c92 | 6ae1b89785f291ca74f2aad9b1178c92_0 |
Centers for Medicare Medicaid Services (CMS) Standard Companion Guide Health Care Claim Payment Advice (835) Based on ASC X12N TR3, Version 005010X221A1 Companion Guide Version Number: 7.1, February 2023 CMS 835 Version 005010 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 835 Version 005010 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 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. iv Table of Contents 1 Introduction.................................................................................................................................................... 1 1.1 Scope.......................................................................................................................................................... 1 1.2 Overview..................................................................................................................................................... 1 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......................................................................................................... 5 4 Connectivity Communications...................................................................................................................... 6 4.1 Process Flows............................................................................................................................................. 6 4.2 Transmission............................................................................................................................................... 6 4.2.1 Re-transmission Procedures.............................................................................................................. 6 4.3 Communication Protocol Specifications.................................................................................................... 6 4.4 Security Protocols and Passwords.............................................................................................................. 7 5 Contact Information........................................................................................................................................ 7 5.1 EDI Customer Service................................................................................................................................. 7 5.2 EDI Technical Assistance............................................................................................................................. 8 5.3 Trading Partner Service Number................................................................................................................ 8 5.4 Applicable Websites Email....................................................................................................................... 8 6 Control Segments Envelopes........................................................................................................................ 9 6.1 ISA-IEA...................................................................................................................................................... 10 Delimiters Inbound Transactions.......................................................................................................... 10 Delimiters Outbound Transactions....................................................................................................... 10 Data Element Detail and Explanation...................................................................................................... 11 6.2 GS-GE........................................................................................................................................................ 11 6.3 ST-SE......................................................................................................................................................... 11 7 Specific Business Rules.................................................................................................................................. 11 8 Acknowledgments and Reports.................................................................................................................... 12 9 Trading Partner Agreement.......................................................................................................................... 12 10 Transaction-Specific Information.................................................................................................................. 12 10.1 Header.................................................................................................................................................... 12 10.1.1 Loop 1000A Payer Identification................................................................................................... 13 10.2 Detail Structures..................................................................................................................................... 14 10.2.1 Loop 2000 Header Number........................................................................................................... 14 10.2.2 Loop 2100 Claim Payment Information........................................................................................ 14 10.2.3 Loop 2110 Service Payment Information...................................................................................... 16 10.3 Summary................................................................................................................................................. 18 CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. v 11 Appendices.................................................................................................................................................... 19 11.1 Implementation Checklist...................................................................................................................... 19 11.2 Transmission Examples.......................................................................................................................... 19 11.3 Frequently Asked Questions.................................................................................................................. 19 11.4 Acronym Listing...................................................................................................................................... 19 11.5 Change Summary.................................................................................................................................... 21 CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. vi List of Tables Table 1. EDI Transactions and Code Set References.................................................................................................. 2 Table 2. Additional EDI Resources.............................................................................................................................. 3 Table 3. ISA Interchange Control Header................................................................................................................... 9 Table 4. GS Functional Group Header...................................................................................................................... 10 Table 5. Outbound Transaction Delimiters............................................................................................................... 10 Table 6. ST Transaction Set Header.......................................................................................................................... 11 Table 7. ST Transaction Set Header.......................................................................................................................... 12 Table 8. BPR Financial Information........................................................................................................................... 13 Table 9. Loop 1000A REF Additional Payer Identifier............................................................................................... 13 Table 10. Loop 2000 LX Header Number.................................................................................................................. 14 Table 11. Loop 2100 CLP Claim Payment Information............................................................................................. 14 Table 12. Loop 2100 CAS Claim Adjustment............................................................................................................. 14 Table 13. Loop 2100 NM1 Patient Name.................................................................................................................. 15 Table 14. Loop 2100 NM1 Insured Name................................................................................................................. 15 Table 15. Loop 2100 NM1 Crossover Carrier Name................................................................................................. 15 Table 16. Loop 2100 REF Other Claim Related Identification................................................................................... 15 Table 17. Loop 2100 REF Rendering Provider Information...................................................................................... 15 Table 18. Loop 2100 AMT Amount Qualifier Code................................................................................................... 16 Table 19. Loop 2100 QTY Claim Supplement Information Quantity........................................................................ 16 Table 20. Loop 2110 SVC Service Payment Information.......................................................................................... 16 Table 21. Loop 2110 CAS Service Adjustment.......................................................................................................... 16 Table 22. Loop 2110 REF Service Identification........................................................................................................ 17 Table 23. Loop 2110 REF Rendering Provider Information...................................................................................... 17 Table 24. Loop 2110 REF Healthcare Policy Identification....................................................................................... 17 Table 25.Loop 2110 AMT Amount Qualifier Code.................................................................................................... 17 Table 26. Loop 2110 LQ Health Care Remark Codes................................................................................................ 17 Table 27. PLB Provider Adjustment.......................................................................................................................... 18 Table 28. Acronym List.............................................................................................................................................. 19 Table 29. Companion Guide Version History............................................................................................................ 21 List of Figures Figure 1. CGS Process Flows....................................................................................................................................... 6 Figure 2. 835 Control Segments and Envelopes....................................................................................................... 19 CMS 835 Version 005010 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 22 Remittance Advice (https: www.cms.gov Regulations-and- Guidance Guidance Manuals downloads clm104c22.pdf) 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 835 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 835 Health Care Claim: Payment Advice transaction Version 005010A1. 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 835 transaction standard to meet Medicare s processing standards. This information is organized in the sections listed below: CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 2 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 835. 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 835 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 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 3 1.4 Additional Information For additional information, please visit the CGS EDI Web page (http: www.cgsmedicare.com partb edi index.html) 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 has been established in order to broadcast urgent messages. Please register for the CGS distribution list (https: www.cgsmedicare.com medicare_dynamic ls 001.asp). Specific information about the above-mentioned items can be found in the following sections. 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. CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 4 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: 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 EDI registration and sign an EDI Enrollment form. The EDI enrollment form (http: www.cgsmedicare.com partb edi enrollment.html) designates the Medicare contractor as the entity they agree to engage in for EDI and ensures agreement between parties to implement standard policies and practices to ensure the security and integrity of information 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 CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 5 Clearinghouse (for Durable Medical Equipment suppliers) to resolve the issue. Once the NPI is properly verified, the provider can reapply the EDI Enrollment Agreement. A Trading Partner s EDI number and password serve as an electronic signature and the Trading Partner would be liable for any improper usage or illegal action performed with it. A Trading Partner s EDI access number and password are not part of the capital property of the Trading Partner s operation and may not be given to a new owner of the Trading Partner 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 on the CGS website (https: www.cgsmedicare.com partb edi enrollment.html). Trading Partners 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. Trading Partners 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 Trading Partner 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 To sign up complete the J15 Communications and the enrollment from (https: www.cgsmedicare.com partb edi enrollment.html). What to expect throughout the process from CGS. 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 field. 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. 3 Testing and Certification Requirements Not applicable. CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 6 4 Connectivity Communications 4.1 Process Flows The following diagrams illustrates how ANSI ASC X12 835 electronic transactions flow into and out of the GPNET, CGS Palmetto GBA's EDI Gateway. Figure 1. CGS Process Flows 4.2 Transmission Please reference the following: GPNet Communications Manual (https: www.cgsmedicare.com partb edi index.html) Connectivity specifications (http: www.cgsmedicare.com pdf gpnet_comm_manual.pdf) 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. 4.3 Communication Protocol Specifications Please see the GPNet Communications Manual posted under the EDI User Guides (https: www.cgsmedicare.com partb edi index.html) webpage. CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 7 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. Login in ID s are assigned once a request is received with a valid EDI application and an EDI enrollment form is on file. EDI transactions submitted by unauthorized Trading partners will not be accepted. Password guidelines are provided with receipt of initial passwords from CGS. 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. Please see our GPnet communications manual posted under the EDI User Guides (https: www.cgsmedicare.com partb edi index.html) webpage. Password guidelines are provided with receipt of initial passwords. Please contact the EDI helpdesk for assistance with passwords and resets. 5 Contact Information 5.1 EDI Customer Service For EDI Customer Service information, please visit the contact us area on our website (https: www.cgsmedicare.com) J15- Part B Correspondence CGS PO box 20018 Nashville, TN 37202 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 CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 8 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 Trading Partner Assistance Information 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) CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 9 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. C.4 ISA04 Security Information - Medicare will send spaces. C.4 ISA05 Interchange ID Qualifier 27, 28, ZZ Medicare will send 27. C.4 ISA06 Interchange Sender ID - CGS contract numbers Ohio Part B 15202 Home Health Hospice 15004 Ohio Part A 15201 Kentucky Part B 15102 Kentucky Part A 15101 C.5 ISA07 Interchange ID Qualifier 29 Medicare will send 29. C.5 ISA08 Interchange Receiver ID - CGS assigned Trading Partner Submitter ID C.5 ISA11 Repetition Separator - Defined by the submitter C.6 ISA14 Acknowledgement Requested 0 Medicare will send 0. CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 10 Note: A hyphen in the table below means N A. Table 4. GS Functional Group Header Page Element Name Codes Content Notes Comments C.7 GS02 Application Sender Code - CGS contract numbers Ohio Part B 15202 Home Health Hospice 15004 Ohio Part A 15201 Kentucky Part B 15102 Kentucky Part A 15101 C.7 GS03 Application Receiver s Code - Trading Partner Receiver ID assigned by CGS. C.8 GS08 Version Identifier Code 005010X221A1 Medicare will send 05010X221A1 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 Not applicable 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 5. Outbound Transaction Delimiters Delimiter Character Used Dec Value Hex Value Data Element Separator 42 2A Repetition Separator 94 5E Component Element Separator 62 3E Segment Terminator 126 7E CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 11 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 4. 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. Note: A hyphen in the table below means N A. Table 6. ST Transaction Set Header Page Loop ID Reference Name Codes Content Notes Comments 111 2000 LX LX Header Number - Required for Medicare. Fiscal Intermediary Standard System (FISS) uses TTYYMM - Facility Code Year Month. MCS uses 1 for assigned and 0 for non-assigned. 171 2100 REF Rendering Provider Identification - Segment not used by Medicare. 206 2110 REF Service Identification Reference Identification Qualifier LU, 1S, APC, RB Medicare does not use BB, E9, G1, or G3. 207 2110 REF Rendering Provider Information Reference Identification Qualifier HPI, SY, TJ, 1C Medicare does not use REF01 Codes 0B, 1A, 1B, 1D, 1H, 1J, D3 or G2. 209 2110 REF Health Care Policy Identification 0K Medicare will report the LCD NCD code in Loop 2110, Segment REF, REF02. CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 12 Page Loop ID Reference Name Codes Content Notes Comments 140 2100 NM1 Insured Name - Segment not used by Medicare. 8 Acknowledgments and Reports The 999 is not used for 835 transactions 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. The CGS Trading Partner Action Request Form can be found on the CGS Website (https: www.cgsmedicare.com partb edi index.html). The CGS Trading Partner Agreement process is part of the overall CGS registration process. Refer to Section 2.2 for details on the agreements required by CGS. 10 Transaction-Specific Information This section defines specific CMS requirements over and above the standard information in the ASC X12N 835 TR3. 10.1 Header The following table contains specific details for the Header. Note: A hyphen in the table below means N A. Table 7. ST Transaction Set Header Page Loop ID Reference Name Codes Content Length Notes Comments 68 N A ST02 Transaction Set Control Number - 9 From one-by-one counter (begins with 0001 ). CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 13 Table 8. BPR Financial Information Page Loop ID Reference Name Codes Content Length Notes Comments 71 N A BPR03 Credit or Debit Flag Code C 1 Code D does not apply to Medicare. 72 N A BPR04 Payment Method Code ACH, CHK, NON 3 Codes BOP and FWT do not apply to Medicare. 73 N A BPR06 Depository Financial Institution (DFI) Identification Number Qualifier 01 2 Code 04 does not apply to Medicare. 75 N A BPR12 Depository Financial Institution (DFI) Identification Number Qualifier 01 2 Code 04 does not apply to Medicare. 10.1.1 Loop 1000A Payer Identification The following table describes the specific details associated with the Payer Identification structure. Note: A hyphen in the table below means N A. Table 9. Loop 1000A REF Additional Payer Identifier Page Loop ID Reference Name Codes Content Length Notes Comments 92 1000A REF01 Reference Identification Qualifier 2U 2 Medicare will send 2U 93 1000A REF02 Reference Identification - 50 CGS reference ID CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 14 10.2 Detail Structures This section describes the specific details associated with Detail Structures. 10.2.1 Loop 2000 Header Number The following table describes the specific details associated with the Header Number structure. Table 10. Loop 2000 LX Header Number Page Loop ID Reference Name Codes Content Length Notes Comments 111 2000 LX01 Assigned Number 0, 1 6 Medicare will send 1 for Assigned or 0 for Non- Assigned. 10.2.2 Loop 2100 Claim Payment Information The following tables describe the specific details associated with the Claim Payment Information structure. Note: A new table exists for each segment. Table 11. Loop 2100 CLP Claim Payment Information Page Loop ID Reference Name Codes Content Length Notes Comments 124 2100 CLP02 Claim Status Code 1, 2, 3, 4, 19, 20, 21, 22, 23 2 25 (Predetermination Pricing Only - No Payment) does not apply to Medicare. 126 2100 CLP06 Claim Filing Indicator Code MA, MB 2 Medicare will send MB for Part B and DME. Medicare will send MA for Part A. Table 12. Loop 2100 CAS Claim Adjustment Page Loop ID Reference Name Codes Content Length Notes Comments 131 2100 CAS01 Claim Adjustment Group Code CO, OA, PR 2 Medicare contractors are limited to use of the CO, OA, and PR group codes; PI is not used. CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 15 Table 13. Loop 2100 NM1 Patient Name Page Loop ID Reference Name Codes Content Length Notes Comments 139 2100 NM108 Patient Name MI 2 Medicare will send MI. Note: A hyphen in the table below means N A. Table 14. Loop 2100 NM1 Insured Name Page Loop ID Reference Name Codes Content Length Notes Comments 140 2100 NM1 Insured Name - N A Segment not used by Medicare Table 15. Loop 2100 NM1 Crossover Carrier Name Page Loop ID Reference Name Codes Content Length Notes Comments 151 2100 NM108 Identification Code Qualifier PI, XV 2 COB transmissions with more than one secondary payer shall indicate remark code N89 in a claim level remark code data element. AD, FI, NI, and PP do not apply to Medicare. Table 16. Loop 2100 REF Other Claim Related Identification Page Loop ID Reference Name Codes Content Length Notes Comments 169 2100 REF01 Reference Identification Qualifier 28, 6P, EA, F8 2 Medicare does not use 1L, 1W, 9A, 9C, BB, CE, G1, G3, or IG. Note: A hyphen in the table below means N A. Table 17. Loop 2100 REF Rendering Provider Information Page Loop ID Reference Name Codes Content Length Notes Comments 171 2100 REF Rendering Provider Information - N A Segment not used by Medicare CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 16 Table 18. Loop 2100 AMT Amount Qualifier Code Page Loop ID Reference Name Codes Content Length Notes Comments 182 2100 AMT01 Amount Qualifier Code AU, DY, F5, I, NL, ZK, ZL, ZM, ZN, ZO 3 Medicare does not use D8, T or T2. Table 19. Loop 2100 QTY Claim Supplement Information Quantity Page Loop ID Reference Name Codes Content Length Notes Comments 184 2100 QTY01 Quantity Qualifier CA, CD, LA, OU, ZK, ZL, ZM, ZN, ZO 2 Medicare does not use LE, NE, NR, PS, or VS. 10.2.3 Loop 2110 Service Payment Information The following tables describe the specific details associated with the Service Payment Information structure. Note: A new table exists for each segment. Table 20. Loop 2110 SVC Service Payment Information Page Loop ID Reference Name Codes Content Length Notes Comments 187 2110 SVC01-1 Product or Service ID Qualifier HC, NU, N4, HP 2 Only HC, NU, N4, and HP apply to Medicare. 191 2110 SVC06-1 Product or Service ID Qualifier HC, NU, N4, HP 2 Only HC, NU, N4, and HP apply to Medicare. Table 21. Loop 2110 CAS Service Adjustment Page Loop ID Reference Name Codes Content Length Notes Comments 198 2110 CAS01 Claim Adjustment Group Code CO, OA, PR 2 Medicare contractors are limited to use of the CO, OA, and PR group codes; PI is not used. CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 17 Table 22. Loop 2110 REF Service Identification Page Loop ID Reference Name Codes Content Length Notes Comments 206 2110 REF01 Services Identification Reference Identification Qualifier LU, 1S, APC, RB 2 Medicare does not use BB, E9, G1 or G3. Table 23. Loop 2110 REF Rendering Provider Information Page Loop ID Reference Name Codes Content Length Notes Comments 207 2110 REF01 Rendering Provider Information Reference Identification Qualifier HPI, SY, TJ, 1C 2 Medicare does not use 0B, 1A, 1B, 1D, 1H, 1J, D3 or G2. Table 24. Loop 2110 REF Healthcare Policy Identification Page Loop ID Reference Name Codes Content Length Notes Comments 209 2110 REF01 Health Care Policy Identification 0K 2 Medicare will report the LCD NCD code in Loop 2110, Segment REF, REF02. Table 25.Loop 2110 AMT Amount Qualifier Code Page Loop ID Reference Name Codes Content Length Notes Comments 211 2110 AMT01 Amount Qualifier Code B6, KH, 2K, ZL, ZM, ZN, ZO 3 Medicare does not use T or T2. Table 26. Loop 2110 LQ Health Care Remark Codes Page Loop ID Reference Name Codes Content Length Notes Comments 215 2110 LQ01 Code List Qualifier Code HE 3 Only HE applies to Medicare. CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 18 10.3 Summary The following table describes the specific details associated with the Summary structure. Table 27. PLB Provider Adjustment Page Loop ID Reference Name Codes Content Length Notes Comments 217 N A PLB03-1 Adjustment Reason Code 50, 51, 72, 90, AP, B2, B3, BD, BN, C5, CS, CV, DM, E3, FB, GO, HM, IP, IS, IR, J1, L3, L6, LE, LS, OA, OB, PI, PL, RA, RE, SL, TL, WO, WU 2 Medicare does not use AH, AM, CR, CT, CW, or FC. CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 19 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 An example of the 835 control segments and envelopes is below. Figure 2. 835 Control Segments and Envelopes 11.3 Frequently Asked Questions Frequently asked questions can be accessed Medicare FFS EDI Operations (https: www.cms.gov ElectronicBillingEDITrans ) and on the CGS Website (https: www.cgsmedicare.com ) and selecting your line of business. 11.4 Acronym Listing Table 28. Acronym List Acronym Definition 276 276 Claim Status Request transaction 277 277 Claim Status Response transaction CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 20 Acronym Definition 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 CMN Certificate of Medical Necessity CMS Centers for Medicare Medicaid Services DME Durable Medical Equipment EDI Electronic Data Interchange ERA Electronic Remittance Advice FFS Medicare Fee-For-Service FISMA Federal Information Security Management Act FISS Fiscal Intermediary Standard System 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 MIME Multipurpose Internet Mail Extensions NCPDP National Council for Prescription Drug Programs NPI National Provider Identifier PECOS Provider Enrollment Chain and Ownership System PHI Protected Health Information CMS 835 Version 005010 Companion Guide 2022 Copyright, CGS Administrators, LLC. 21 Acronym Definition 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 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 11.5 Change Summary The following table contains version information of this CG. Table 29. 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 August 2017 All Updated CGS and CMS URL 6.0 March 2019 All 4th Publication Version 6.1 June 2020 1.3, 11.41 Updated WPC and X12 web addresses 7.0 July 2022 All 508 Compliance updates 7.1 February 2023 2.2 Removed incorrect reference to CEDI | /kaggle/input/edi-db-835-837/835_compguide.pdf | 8f5ce796cfe2b11469b1ad79fc23d162 | 8f5ce796cfe2b11469b1ad79fc23d162_0 |
Stedi maintains this guide based on public documentation from United Healthcare. Contact United Healthcare for official EDI specifications. To report any errors in this guide, please contact us. X12 837 Health Care Claim: Dental (X224A3) 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 View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view united-healthcare health-care-claim-dental- x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 1 413 POWERED BY Build EDI implementation guides at stedi.com 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 2 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 3 413 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 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 Date - Accident Max use 1 Optional DTP 1350 Date - Appliance Placement Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional DTP 1350 Date - Service Date Max use 1 Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 4 413 DN1 1450 Orthodontic Total Months of Treatment Max use 1 Optional DN2 1500 Tooth Status Max use 35 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 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Predetermination Identification 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 5 Optional HI 2310 Health Care Diagnosis Code Max use 1 Optional HCP 2410 Claim Pricing Repricing Information Max use 1 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required PRV 2550 Referring Provider Specialty Information Max use 1 Optional 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 5 413 REF 2710 Service Facility Location Secondary Identification Max use 3 Optional Assistant Surgeon Name Loop NM1 2500 Assistant Surgeon Name Max use 1 Required PRV 2550 Assistant Surgeon Specialty Information Max use 1 Required REF 2710 Assistant Surgeon Secondary Identification Max use 4 Optional Supervising Provider Name Loop NM1 2500 Supervising Provider Name Max use 1 Required REF 2710 Supervising Provider Secondary Identification Max use 4 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 6 413 REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Predetermination Identification 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 3 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 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 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 Assistant Surgeon Loop NM1 3250 Other Payer Assistant Surgeon Max use 1 Required REF 3550 Other Payer Assistant Surgeon Secondary Identifier Max use 3 Required Service Line Number Loop LX 3650 Service Line Number Max use 1 Required 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 7 413 SV3 3800 Dental Service Max use 1 Required TOO 3820 Tooth Information Max use 32 Optional DTP 4550 Date - Appliance Placement Max use 1 Optional DTP 4550 Date - Prior Placement Max use 1 Optional DTP 4550 Date - Replacement Max use 1 Optional DTP 4550 Date - Service Date Max use 1 Optional DTP 4550 Date - Treatment Completion Max use 1 Optional DTP 4550 Date - Treatment Start Max use 1 Optional CN1 4650 Contract Information Max use 1 Optional REF 4700 Adjusted Repriced Claim Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Prior Authorization Max use 5 Optional REF 4700 Referral Number Max use 5 Optional REF 4700 Repriced Claim Number Max use 1 Optional REF 4700 Service Predetermination Identification Max use 5 Optional AMT 4750 Sales Tax Amount Max use 1 Optional K3 4800 File Information Max use 10 Optional HCP 4920 Line Pricing Repricing Information 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 Required REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Assistant Surgeon Name Loop NM1 5000 Assistant Surgeon Name Max use 1 Required PRV 5050 Assistant Surgeon Specialty Information Max use 1 Optional REF 5250 Assistant Surgeon Secondary Identification Max use 20 Optional Supervising Provider Name Loop NM1 5000 Supervising Provider Name Max use 1 Required REF 5250 Supervising Provider Secondary Identification Max use 20 Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 8 413 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 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 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 Date - Accident Max use 1 Optional DTP 1350 Date - Appliance Placement Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional DTP 1350 Date - Service Date Max use 1 Optional DN1 1450 Orthodontic Total Months of Treatment Max use 1 Optional DN2 1500 Tooth Status Max use 35 Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 9 413 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 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Predetermination Identification 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 5 Optional HI 2310 Health Care Diagnosis Code Max use 1 Optional HCP 2410 Claim Pricing Repricing Information Max use 1 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required PRV 2550 Referring Provider Specialty Information Max use 1 Optional 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 10 413 Assistant Surgeon Name Loop NM1 2500 Assistant Surgeon Name Max use 1 Required PRV 2550 Assistant Surgeon Specialty Information Max use 1 Required REF 2710 Assistant Surgeon Secondary Identification Max use 4 Optional Supervising Provider Name Loop NM1 2500 Supervising Provider Name Max use 1 Required REF 2710 Supervising Provider Secondary Identification Max use 4 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 11 413 REF 3550 Other Payer Predetermination Identification 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 3 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 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 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 Assistant Surgeon Loop NM1 3250 Other Payer Assistant Surgeon Max use 1 Required REF 3550 Other Payer Assistant Surgeon Secondary Identifier Max use 3 Required Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV3 3800 Dental Service Max use 1 Required 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 12 413 TOO 3820 Tooth Information Max use 32 Optional DTP 4550 Date - Appliance Placement Max use 1 Optional DTP 4550 Date - Prior Placement Max use 1 Optional DTP 4550 Date - Replacement Max use 1 Optional DTP 4550 Date - Service Date Max use 1 Optional DTP 4550 Date - Treatment Completion Max use 1 Optional DTP 4550 Date - Treatment Start Max use 1 Optional CN1 4650 Contract Information Max use 1 Optional REF 4700 Adjusted Repriced Claim Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Prior Authorization Max use 5 Optional REF 4700 Referral Number Max use 5 Optional REF 4700 Repriced Claim Number Max use 1 Optional REF 4700 Service Predetermination Identification Max use 5 Optional AMT 4750 Sales Tax Amount Max use 1 Optional K3 4800 File Information Max use 10 Optional HCP 4920 Line Pricing Repricing Information 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 Required REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Assistant Surgeon Name Loop NM1 5000 Assistant Surgeon Name Max use 1 Required PRV 5050 Assistant Surgeon Specialty Information Max use 1 Optional REF 5250 Assistant Surgeon Secondary Identification Max use 20 Optional Supervising Provider Name Loop NM1 5000 Supervising Provider Name Max use 1 Required REF 5250 Supervising Provider Secondary Identification Max use 20 Optional Service Facility Location Name Loop 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 13 413 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 14 413 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 0549 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 15 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 16 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 17 413 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HC XXXXXX XXXXX 20250131 0052 00 XX 005010X224 A3 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 18 413 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 005010X224A3 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 19 413 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 005010X224A3 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. 005010X224A3 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 20 413 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 XXXX 20250131 0424 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 21 413 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. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 22 413 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 X X XXXX 46 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 23 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 24 413 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 EM XXXX EM XXXX EX XXXXXX 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 25 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 26 413 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 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 27 413 Heading end 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 28 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 29 413 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 Billing Provider is also the Rendering Provider for at least one of the claims in this transaction. If not required by this implementation guide, do not send. Example PRV BI PXC X 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 30 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 31 413 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 1 XXXXXX XXXXXX XXXX XX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 32 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 33 413 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 XXXX XXXXXX Max use 1 Required N3-01 166 Billing Provider Address Line Min 1 Max 55 String (AN) Required Address information Usage notes Follow the 5010 Implementation Guide; Dental recommends sending the full street address. N3-02 166 Billing Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 34 413 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 XXXXXX 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 35 413 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 36 413 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 XXXXX 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. 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 Usage notes This segment must contain tax identification 2010ABnumber of the billing provider. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental | /kaggle/input/edi-db-835-837/United Healthcare 837 Health Care Claim_ Dental.pdf | e52a8425126fbab9db1413c494cc97ed | e52a8425126fbab9db1413c494cc97ed_0 |
full street address. N3-02 166 Billing Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 34 413 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 XXXXXX 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 35 413 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 36 413 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 XXXXX 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. 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 Usage notes This segment must contain tax identification 2010ABnumber of the billing provider. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 37 413 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 XXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 38 413 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 FX XXXXXX FX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 39 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 40 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 41 413 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 XXXX Max use 1 Required N3-01 166 Pay-To Address Line Min 1 Max 55 String (AN) Required Address information Usage notes Follow the 5010 Implementation Guide. Dental recommends sending the full street address rather than a PO Box address. N3-02 166 Pay-To Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 42 413 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 XXXX XXX Only one of Pay-To Address 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 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 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 43 413 2010AB Pay-to Address Name Loop end 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 44 413 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 XXXXXX 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 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 On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent. Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 45 413 If a phase-in period is designated, PI must be sent unless: Both the sender and receiver agree to use the National Plan ID, The receiver has a National Plan ID, and The sender has the capability to send the National Plan ID. If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U. 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 46 413 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 XXX XXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 47 413 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 XXXXXXX XX XXXXXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 48 413 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 prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the 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 2U XXXXXX 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 National Plan Identifier is reported in NM109 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 49 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 50 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 51 413 0 No Subordinate HL Segment in This Hierarchical Structure. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 52 413 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 T 18 XXXX XXX 13 FI 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 53 413 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) Optional 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 54 413 ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 55 413 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 XX XXX XX II 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 56 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 57 413 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 X 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 58 413 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 XXXXX XX XXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 59 413 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 60 413 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 XXXXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 61 413 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 XXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 62 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 63 413 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 XX 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 On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent. Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent. If a phase-in period is designated, PI must be sent unless: Both the sender and receiver agree to use the National Plan ID, 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 64 413 The receiver has a National Plan ID, and The sender has the capability to send the National Plan ID. If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U. 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 65 413 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 XX 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 66 413 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 67 413 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 68 413 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 XXXXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 69 413 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 prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the 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 FY XXXXXX 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 National Plan Identifier is reported in NM109 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 70 413 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 XX 00000 XX B X N C Y I AA XX XX XXX 05 PB 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. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 71 413 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 Dental Service (SV3) 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 72 413 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. C Not Assigned Required when code A' does not 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 For this Implementation Guide, this also applies to dental billing data related to a claim. 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 73 413 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 01 Early Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP) 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. CLM-19 1383 Predetermination of Benefits Code Identifier (ID) Optional Code identifying reason for claim submission PB Predetermination of Dental Benefits CLM-20 1514 Delay Reason Code Identifier (ID) Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 74 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 75 413 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 - Appliance | /kaggle/input/edi-db-835-837/United Healthcare 837 Health Care Claim_ Dental.pdf | e52a8425126fbab9db1413c494cc97ed | e52a8425126fbab9db1413c494cc97ed_1 |
data related to a claim. 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 73 413 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 01 Early Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP) 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. CLM-19 1383 Predetermination of Benefits Code Identifier (ID) Optional Code identifying reason for claim submission PB Predetermination of Dental Benefits CLM-20 1514 Delay Reason Code Identifier (ID) Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 74 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 75 413 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 - Appliance Placement DTP Date - Repricer Received Date DTP Date - Service 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 76 413 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Appliance Placement To specify any or all of a date, a time, or a time period Usage notes Required when reporting the date orthodontic appliances were placed. 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 452 D8 XXXX Variants (all may be used) DTP Date - Accident DTP Date - Repricer Received Date DTP Date - Service 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 452 Appliance Placement 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 Orthodontic Banding 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 77 413 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 - Appliance Placement DTP Date - Service 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 78 413 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes Required when all of the services for this claim were performed. Not used when the claim is being submitted as a Predetermination of Benefits. 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 472 D8 XXXXX Variants (all may be used) DTP Date - Accident DTP Date - Appliance Placement 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 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. 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 79 413 DN1 1450 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DN1 Orthodontic Total Months of Treatment To supply orthodontic information Usage notes Required when the claim contains services related to treatment for orthodontic purposes. If not required by this implementation guide, do not send. When reporting this segment, at least one of DN101, DN102 or DN104 must be present. Example DN1 00000000 000000 XXXXX Max use 1 Optional DN1-01 380 Orthodontic Treatment Months Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity DN101 is the estimated number of treatment months. DN1-02 380 Orthodontic Treatment Months Remaining Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity DN102 is the number of treatment months remaining. DN1-04 352 Orthodontic Treatment Indicator Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content DN104 is the appliance description. Usage notes The only allowed value for DN104 is "Y", which indicates that services reported on this claim are for orthodontic purposes and that both DN101 and DN102 were not submitted. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 80 413 DN2 1500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DN2 Tooth Status To specify the status of individual teeth Usage notes Required when the submitter is reporting a missing tooth or a tooth to be extracted in the future. If not required by this implementation guide, do not send. Example DN2 XXXX E JP Max use 35 Optional DN2-01 127 Tooth 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 DN201 is the tooth number. Usage notes The Universal National Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association. DN2-02 1368 Tooth Status Code Identifier (ID) Required Code specifying the status of the tooth E To Be Extracted M Missing DN2-06 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list DN206 designates the code set used to identify the tooth in DN201. JP Universal National Tooth Designation System 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 81 413 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 B4 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 B4 Referral Form DA Dental Models DG Diagnostic Report EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) OZ Support Data for Claim P6 Periodontal Charts RB Radiology Films RR Radiology Reports 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 82 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 83 413 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 06 0000000 0 XXXXX 000000 XXX Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 84 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 85 413 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 000000000000 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 86 413 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 Claim Identifier For Transmission Intermediaries REF Payer Claim Control Number REF Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 87 413 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 Payer Claim Control Number REF Predetermination Identification 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 88 413 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 Claim Identifier For Transmission Intermediaries REF Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 89 413 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Predetermination Identification To specify identifying information Usage notes Required when sending the Predetermination of Benefits Identification Number for services that have been previously predetermined and are now being submitted for payment. If not required by this implementation guide, do not send. Reference numbers at this position apply to the entire claim. Example REF G3 XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries 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 G3 Predetermination of Benefits Identification Number REF-02 127 Predetermination of Benefits 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 90 413 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. 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. This segment must not be used to report the Predetermination of Benefits Identification Number. 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 G1 X Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Payer Claim Control Number REF Predetermination Identification 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 91 413 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 92 413 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. This segment must not be used to report the Predetermination of Benefits Identification Number. Example REF 9F XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Payer Claim Control Number REF Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 93 413 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 XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Payer Claim Control Number REF Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 94 413 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 XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Payer Claim Control Number REF Predetermination Identification 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 95 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 96 413 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. 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 ADD XXXXX Max use 5 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 97 413 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. Required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions. If not required by this implementation guide, do not send. Example HI ABK XXXX BF X XXX X XXX X 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. 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 TQ Systemized Nomenclature of Dentistry (SNODENT) 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 SNODENT codes as an allowable code set under HIPAA, OR the Secretary of Health and Human Services grants an exception to use the code set as a pilot project. C022-02 1271 Principal 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 98 413 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 TQ Systemized Nomenclature of Dentistry (SNODENT) 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 SNODENT codes as an allowable code set under HIPAA, OR the Secretary of Health and Human Services grants an exception to use the code set as a pilot project. 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 Code List Qualifier Code Min 1 Max 3 Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. Usage notes 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 99 413 See element HI02-1 for a list of valid values. 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 Code List Qualifier Code Min 1 Max 3 Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. Usage notes See element HI02-1 for a list of valid values. 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 100 413 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 000000000 0 XX 000 XXX T1 3 3 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. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 101 413 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-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. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 102 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 103 413 2310A Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Assistant Surgeon Name Loop Supervising Provider 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 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 the 2310A loop at the claim 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. Example NM1 P3 1 XXXXX XXXX XXXXX XXX 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 Code qualifying the type of entity NM102 qualifies NM103. 1 Person 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 104 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 105 413 PRV 2550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop PRV Referring 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 RF PXC XXXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider RF Referring 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 106 413 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 107 413 2310B Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Service Facility Location Name Loop Assistant Surgeon Name Loop Supervising 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 NM1 information is different than that carried in the Billing Provider loop (Loop ID-2010AA) and the Assistant Surgeon loop (Loop ID- 2310D) is not used. 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 XXXXX X X 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 String (AN) Required Min 1 Max 60 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 108 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 109 413 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 | /kaggle/input/edi-db-835-837/United Healthcare 837 Health Care Claim_ Dental.pdf | e52a8425126fbab9db1413c494cc97ed | e52a8425126fbab9db1413c494cc97ed_2 |
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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 107 413 2310B Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Service Facility Location Name Loop Assistant Surgeon Name Loop Supervising 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 NM1 information is different than that carried in the Billing Provider loop (Loop ID-2010AA) and the Assistant Surgeon loop (Loop ID- 2310D) is not used. 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 XXXXX X X 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 String (AN) Required Min 1 Max 60 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 108 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 109 413 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 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 Required 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 110 413 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 111 413 2310C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Assistant Surgeon Name Loop Supervising 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. When the service(s) was rendered in the patient's home (the address reported as the patient address in the Subscriber or Patient loop), do not use the Service Facility Location loop. In that case, the place of service code in CLM05-1 indicates that the service occurred in the patient's home. The purpose of this loop is to identify specifically where the service was rendered. 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 XX 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 Usage notes UnitedHealthcare Dental will use the code 77 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 112 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 113 413 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 XX Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information Usage notes Follow the 5010 Implementation Guide. Dental recommends sending the full street address rather than a PO Box address. N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 114 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 115 413 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 116 413 2310C 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 G2 XXXXXX 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 117 413 2310D Assistant Surgeon Name 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 NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Assistant Surgeon Name Loop NM1 Assistant Surgeon Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider provided these services in the role of the Assisting Surgeon. 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 DD 1 XXXX XXX XXXXX X XX XXXXXXX If either Identification Code Qualifier (NM1-08) or Assistant Surgeon 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 DD Assistant Surgeon NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Assistant Surgeon Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Assistant Surgeon First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 118 413 Individual first name NM1-05 1037 Assistant Surgeon Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Assistant Surgeon 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) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Assistant Surgeon Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 119 413 PRV 2550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Assistant Surgeon Name Loop PRV Assistant Surgeon Specialty Information To specify the identifying characteristics of a provider Usage notes 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 PRV AS PXC XXX Max use 1 Required PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider AS Assistant Surgeon 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 120 413 2310D Assistant Surgeon Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Assistant Surgeon Name Loop REF Assistant Surgeon 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 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 Assistant Surgeon 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 121 413 2310E 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 Assistant Surgeon Name 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 or dentist. 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 XXX XX X XXXXX 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 Use this code for the supervising dentist or 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 122 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 123 413 2310E 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 when the HIPAA National Provider Identifier (NPI) is not reported in NM109 of this loop; OR Required for Health Care Providers prior to the mandated NPI implementation date when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider; OR Required for providers who are not Health Care Providers when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF 0B 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 124 413 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 21 XXXXX XXX 12 DS 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 125 413 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) Optional 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 126 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 127 413 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 X 000000 00000000 XXX 00000000000 00000000 0000 XX 0 000 XX 0 0000000000000 XXXX 00000 00000 00 XXXXX 00000000000 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 Max use 5 Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 128 413 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 129 413 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 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 130 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 131 413 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 0000 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 132 413 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 000 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 133 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 134 413 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 Y 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 element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. This is a crosswalk from CLM08 when doing COB. 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 The Release of Information response is limited to the information carried in this claim. This is a crosswalk from CLM09 when doing COB. 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 135 413 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 0000000 00000000000 X XXXX XX XXXXXX XXXX 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 136 413 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-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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 137 413 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 Supervising Provider Loop Other Payer Billing Provider Loop Other Payer Service Facility Location Loop Other Payer Assistant Surgeon 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 XXX XXX XXXXXX XX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 138 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 139 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 140 413 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 XX XX XXX 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 141 413 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 142 413 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 143 413 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 Supervising Provider Loop Other Payer Billing Provider Loop Other Payer Service Facility Location Loop Other Payer Assistant Surgeon 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 XXX PI 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 144 413 On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be | /kaggle/input/edi-db-835-837/United Healthcare 837 Health Care Claim_ Dental.pdf | e52a8425126fbab9db1413c494cc97ed | e52a8425126fbab9db1413c494cc97ed_3 |
Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 141 413 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 142 413 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 143 413 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 Supervising Provider Loop Other Payer Billing Provider Loop Other Payer Service Facility Location Loop Other Payer Assistant Surgeon 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 XXX PI 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 144 413 On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent. Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent. If a phase-in period is designated, PI must be sent unless: Both the sender and receiver agree to use the National Plan ID, The receiver has a National Plan ID, and The sender has the capability to send the National Plan ID. If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U. 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 145 413 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 XXXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 146 413 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 XXX XX XXX 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 147 413 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 148 413 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 149 413 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 XXXXXX Variants (all may be used) REF Other Payer Claim Control Number REF Other Payer Predetermination Identification 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 150 413 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 Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 151 413 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 Predetermination Identification To specify identifying information Usage notes Required when the payer identified in this loop has assigned a predetermination identification number to this claim. If not required by this implementation guide, do not send. Example REF G3 XXXXX 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 REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G3 Predetermination of Benefits Identification Number REF-02 127 Other Payer Predetermination of Benefits 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 152 413 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 This segment must not be used to report the Predetermination of Benefits Identification Number. 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 Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 153 413 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 XX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Predetermination Identification 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 154 413 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 prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the 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 2U X Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Predetermination Identification REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 155 413 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 Supervising Provider Loop Other Payer Billing Provider Loop Other Payer Service Facility Location Loop Other Payer Assistant Surgeon 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 156 413 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 157 413 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 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 158 413 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 Supervising Provider Loop Other Payer Billing Provider Loop Other Payer Service Facility Location Loop Other Payer Assistant Surgeon 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 159 413 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 See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF LU 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 160 413 2330E 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 Billing Provider Loop Other Payer Service Facility Location Loop Other Payer Assistant Surgeon 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 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 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 Use this code for the supervising dentist or physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 161 413 1 Person 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 162 413 2330E 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 Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF LU 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 163 413 2330F 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 Supervising Provider Loop Other Payer Service Facility Location Loop Other Payer Assistant Surgeon 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 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 164 413 1 Person 2 Non-Person Entity 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 165 413 2330F Other Payer Billing Provider 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 X 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 166 413 2330G 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 Other Payer Assistant Surgeon 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 167 413 2 Non-Person Entity 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 168 413 2330G 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 XXXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 169 413 2330H Other Payer Assistant Surgeon 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 Other Payer Service Facility Location Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Assistant Surgeon Loop NM1 Other Payer Assistant Surgeon 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 DD 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 DD Assistant Surgeon NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 170 413 1 Person 2 Non-Person Entity 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 171 413 2330H Other Payer Assistant Surgeon 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 Assistant Surgeon Loop REF Other Payer Assistant Surgeon Secondary Identifier 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 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 Assistant Surgeon 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 172 413 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 173 413 SV3 3800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop SV3 Dental Service To specify the service line item detail for dental work Example SV3 AD XXXX XX XX XX XX XXXXXX 0000000 X XXX XX X X X XX R 00000 00 00 0 00 Max use 1 Required SV3-01 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. AD American Dental Association Codes CDT Current Dental Terminology 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. Usage notes A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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. Usage notes 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 174 413 A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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 A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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. Usage notes A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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. SV3-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SV302 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. SV3-03 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. SV303 is the place of service code representing the location where the dental treatment was rendered. Usage notes 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 175 413 See CODE SOURCE 237: Place of Service Codes for Professional Claims SV3-04 C006 Oral Cavity Designation To identify one or more areas of the oral cavity Usage notes Required when the nomenclature associated with the procedure reported in SV301-2 refers to quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure description. Report individual tooth numbers in one or more TOO segments. Max use 1 Optional C006-01 1361 Oral Cavity Designation Code Min 1 Max 3 Identifier (ID) Required Code Identifying the area of the oral cavity in which service is rendered C006-02 1361 Oral Cavity Designation Code Min 1 Max 3 Identifier (ID) Optional Code Identifying the area of the oral cavity in which service is rendered C006-03 1361 Oral Cavity Designation Code Min 1 Max 3 Identifier (ID) Optional Code Identifying the area of the oral cavity in which service is rendered C006-04 1361 Oral Cavity Designation Code Min 1 Max 3 Identifier (ID) Optional Code Identifying the area of the oral cavity in which service is rendered C006-05 1361 Oral Cavity Designation Code Min 1 Max 3 Identifier (ID) Optional Code Identifying the area of the oral cavity in which service is rendered SV3-05 1358 Prosthesis, Crown, or Inlay Code Identifier (ID) Optional Code specifying the placement status for the dental work I Initial Placement R Replacement When SV305 R, then the DTP segment in the 2400 loop for Prior Placement is Required. SV3-06 380 Procedure Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SV306 is the number of procedures. Usage notes 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 176 413 Number of procedures SV3-11 C004 Composite Diagnosis Code Pointer To identify one or more diagnosis code pointers Usage notes Required when the service relates to that specific diagnosis and is needed to substantiate the medical treatment. If not required by this implementation guide, do not send. Max use 1 Optional 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. 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. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 177 413 TOO 3820 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop TOO Tooth Information To identify a tooth by number and, if applicable, one or more tooth surfaces Usage notes Required when reporting tooth information related to this service line. If not required by this implementation guide, do not send. Multiple iterations of the TOO segment are allowed only when the quantity reported in Loop ID-2400 SV306 is equal to one. Example TOO JP XXXXXX M XX XX X X Max use 32 Optional TOO-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list JP Universal National Tooth Designation System TOO-02 1271 Tooth Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list Usage notes See Appendix A for code source 135: American Dental Association Codes. This element may only be used to report individual teeth. It may not be used to report areas of the oral cavity such as quadrants or sextants. Areas of the oral cavity must be reported in one or more of the components of SV304. TOO-03 C005 Tooth Surface To identify one or more tooth surface codes Usage notes Required when the procedure code requires tooth surface codes. If not required by this implementation guide, do not send. Max use 1 Optional C005-01 1369 Tooth Surface Code Identifier (ID) Required Code identifying the area of the tooth that was treated 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 178 413 B Buccal D Distal F Facial I Incisal L Lingual M Mesial O Occlusal C005-02 1369 Tooth Surface Code Min 1 Max 2 Identifier (ID) Optional Code identifying the area of the tooth that was treated Usage notes Additional tooth surface codes can be carried in TOO03-2 through TOO03-5. The code values are the same as in TOO03-1. C005-03 1369 Tooth Surface Code Min 1 Max 2 Identifier (ID) Optional Code identifying the area of the tooth that was treated C005-04 1369 Tooth Surface Code Min 1 Max 2 Identifier (ID) Optional Code identifying the area of the tooth that was treated C005-05 1369 Tooth Surface Code Min 1 Max 2 Identifier (ID) Optional Code identifying the area of the tooth that was treated 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 179 413 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Appliance Placement To specify any or all of a date, a time, or a time period Usage notes Required when the orthodontic appliance placement date is different than the orthodontic appliance placement date in the DTP segment in the Loop ID-2300 loop. If not required by this implementation guide, do not send.; Example DTP 452 D8 XXX Variants (all may be used) DTP Date - Prior Placement DTP Date - Replacement DTP Date - Service Date DTP Date - Treatment Completion DTP Date - Treatment Start 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 452 Appliance Placement 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 Orthodontic Banding 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 180 413 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Prior Placement To specify any or all of a date, a time, or a time period Usage notes Required when the value of SV305 for this iteration of the 2400 loop is R - Replacement. If not required by this implementation guide, do not send. Example DTP 441 D8 XXXXX Variants (all may be used) DTP Date - Appliance Placement DTP Date - Replacement DTP Date - Service Date DTP Date - Treatment Completion DTP Date - Treatment Start 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 139 Estimated Required when the exact Prior Placement Date is not known. 441 Prior Placement Required when the exact Prior Placement Date is known. 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 Prior Placement 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 181 413 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Replacement To specify any or all of a date, a time, or a time period Usage notes Required when reporting the date that an orthodontic appliance was replaced. If not required by this implementation guide, do not send. Example DTP 446 D8 XXXXXX Variants (all may be used) DTP Date - Appliance Placement DTP Date - Prior Placement DTP Date - Service Date DTP Date - Treatment Completion DTP Date - Treatment Start 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 446 Replacement 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 Replacement 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 182 413 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 when the service was performed and the service date is different than the date reported in the Service Date segment in the 2300 loop. If not required by | /kaggle/input/edi-db-835-837/United Healthcare 837 Health Care Claim_ Dental.pdf | e52a8425126fbab9db1413c494cc97ed | e52a8425126fbab9db1413c494cc97ed_4 |
Loop DTP Date - Prior Placement To specify any or all of a date, a time, or a time period Usage notes Required when the value of SV305 for this iteration of the 2400 loop is R - Replacement. If not required by this implementation guide, do not send. Example DTP 441 D8 XXXXX Variants (all may be used) DTP Date - Appliance Placement DTP Date - Replacement DTP Date - Service Date DTP Date - Treatment Completion DTP Date - Treatment Start 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 139 Estimated Required when the exact Prior Placement Date is not known. 441 Prior Placement Required when the exact Prior Placement Date is known. 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 Prior Placement 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 181 413 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Replacement To specify any or all of a date, a time, or a time period Usage notes Required when reporting the date that an orthodontic appliance was replaced. If not required by this implementation guide, do not send. Example DTP 446 D8 XXXXXX Variants (all may be used) DTP Date - Appliance Placement DTP Date - Prior Placement DTP Date - Service Date DTP Date - Treatment Completion DTP Date - Treatment Start 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 446 Replacement 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 Replacement 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 182 413 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 when the service was performed and the service date is different than the date reported in the Service Date segment in the 2300 loop. If not required by this implementation guide, do not send. Do not use this DTP segment when submitting a Predetermination of Dental Benefits. Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both. Example DTP 472 D8 XXXX Variants (all may be used) DTP Date - Appliance Placement DTP Date - Prior Placement DTP Date - Replacement DTP Date - Treatment Completion DTP Date - Treatment Start 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. D8 Date Expressed in Format 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 183 413 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Treatment Completion To specify any or all of a date, a time, or a time period Usage notes Required when reporting the date that a course of treatment was completed. If not required by this implementation guide, do not send. When the Treatment Completion Date is used, the Date of Service must not be used. Example DTP 198 D8 XXXXXX Variants (all may be used) DTP Date - Appliance Placement DTP Date - Prior Placement DTP Date - Replacement DTP Date - Service Date DTP Date - Treatment Start 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 198 Completion 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 Completion 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 184 413 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Treatment Start To specify any or all of a date, a time, or a time period Usage notes Required when reporting initial impression or preparation for a crown or denture. OR Required when reporting initial endodontic treatment. OR Required when reporting the implant fixture placement. If not required by this implementation guide, do not send. When the Treatment Start Date is used, the Date of Service must not be used. Example DTP 196 D8 XXXXXX Variants (all may be used) DTP Date - Appliance Placement DTP Date - Prior Placement DTP Date - Replacement DTP Date - Service Date DTP Date - Treatment Completion 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 196 Start 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 Start 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 185 413 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 03 0 0000 XXX 000 XXX Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 186 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 187 413 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number 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 Line Item Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 188 413 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 Claim Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Predetermination 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 189 413 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 This segment must not be used to report the Predetermination of Benefits Identification Number. 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 XXX 2U XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Line Item Control Number REF Referral Number REF Repriced Claim Number REF Service Predetermination Identification 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 190 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 191 413 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 XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Line Item Control Number REF Prior Authorization REF Repriced Claim Number REF Service Predetermination Identification 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 192 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 193 413 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number 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 Line Item Control Number REF Prior Authorization REF Referral Number REF Service Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 194 413 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Service Predetermination Identification To specify identifying information Usage notes Required when sending the Predetermination of Benefits Identification Number for the line item that has been previously predetermined and is now being submitted for payment. If not required by this implementation guide, do not send. Reference numbers at this position apply to the current line item only. 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 G3 XX 2U XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Line Item Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G3 Predetermination of Benefits Identification Number REF-02 127 Predetermination of Benefits 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 Predetermination Identification 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 195 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 196 413 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 (SV302) for this service line must include the amount reported in the Sales Tax Amount. Example AMT T 00000000000 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 197 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 198 413 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 01 000000000000000 00000000000000 X 000000 AD XXXXXX UN 0000 T3 5 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 199 413 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-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) AD American Dental Association Codes 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 200 413 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 5 State Mandates 6 Other 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 201 413 2420A Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Assistant Surgeon Name Loop Supervising Provider Name Loop Service Facility Location 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 the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider and the Assistant Surgeon (Loop ID-2420C) loop is not present OR Required when each of the following conditions apply: the Rendering Provider information is carried at the Billing Provider level (Loop ID- 2010AA) this particular line item has different Rendering Provider information than that which is carried in the Loop ID-2010AA Billing Provider the Assistant Surgeon loop (Loop ID-2420C) is not used. 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. Example NM1 82 1 XXXXXX XX XXXXXX X XX XXX 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 202 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 203 413 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 Example PRV PE PXC XXXXXX Max use 1 Required 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 204 413 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 LU XXXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 205 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 206 413 2420B Assistant Surgeon Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Supervising Provider Name Loop Service Facility Location Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Assistant Surgeon Name Loop NM1 Assistant Surgeon Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider provided these services in the role of the Assistant Surgeon and the Assistant Surgeon information in this loop is different from the Assistant Surgeon information sent in Loop ID-2310D. If not required by this implementation guide, do not send.; Example NM1 DD 1 XX X X XXXX XX XXXXXXX If either Identification Code Qualifier (NM1-08) or Assistant Surgeon 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 DD Assistant Surgeon NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Assistant Surgeon Last or Organization Name String (AN) Required Min 1 Max 60 Individual last name or organizational name NM1-04 1036 Assistant Surgeon First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 207 413 Individual first name NM1-05 1037 Assistant Surgeon Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Assistant Surgeon 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 Assistant Surgeon Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 208 413 PRV 5050 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Assistant Surgeon Name Loop PRV Assistant Surgeon Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the Assistant Surgeon specialty information is needed to facilitate reimbursement of the claim. If not required by this implementation guide, do not send.; Example PRV AS PXC XXXXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider AS Assistant Surgeon 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 209 413 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Assistant Surgeon Name Loop REF Assistant Surgeon 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 send provider identifiers that are not payer-specific (e.g. UPIN, State License Number), those identifiers must be sent in the corresponding 2310 loop. 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 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 Assistant Surgeon 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 Max use 1 Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 210 413 2420B Assistant Surgeon 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 211 413 2420C Supervising Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Assistant Surgeon Name Loop Service Facility Location Name 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 or dentist and the supervising physician or dentist 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 X XXXX XX XXXX 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 Use this code for the supervising dentist or 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 212 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 213 413 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 this segment is used, the identifier(s) to be provided are limited to those necessary for the claim processor to identify the entity. 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 XXXXX 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 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 Max use 1 Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 214 413 2420C Supervising 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 215 413 2420D Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Assistant Surgeon Name Loop Supervising Provider Name 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. Example NM1 77 2 XXXXX 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 Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 216 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 217 413 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 X 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 218 413 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 XX 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 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 | /kaggle/input/edi-db-835-837/United Healthcare 837 Health Care Claim_ Dental.pdf | e52a8425126fbab9db1413c494cc97ed | e52a8425126fbab9db1413c494cc97ed_5 |
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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 216 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 217 413 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 X 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 218 413 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 XX 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 219 413 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 220 413 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 1G XXX 2U XXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 221 413 2420D Service Facility Location 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 222 413 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 XXXXXX 00 ER X XX XX XX XX XX 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. Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 223 413 Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply 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. Usage notes This is the first procedure code modifier. A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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. Usage notes This is the second procedure code modifier. A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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 This is the third procedure code modifier. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 224 413 A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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. Usage notes This is the fourth procedure code modifier. A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 225 413 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 PI XXXXX 000 00000000 XX 0000 000000 XX 00000 000000000 00000000 XXX 0000000 0000000 XX 0000000 000 00000000 XXXXX 000000000000000 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 226 413 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 227 413 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 228 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 229 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 230 413 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 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. 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 not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 231 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 232 413 0 No Subordinate HL Segment in This Hierarchical Structure. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 233 413 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 20 Max use 1 Required PAT-01 1069 Individual Relationship Code Identifier (ID) Required Code indicating the relationship between two individuals or entities 01 Spouse 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 234 413 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 XXX XX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 235 413 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 XXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 236 413 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 XXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 237 413 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 XXXXX F 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 238 413 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 XXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 239 413 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 240 413 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 00 X B X N C N I AA XX XX XX 01 P B 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 241 413 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 Dental Service (SV3) 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 242 413 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. C Not Assigned Required when code A' does not 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 For this Implementation Guide, this also applies to dental billing data related to a claim. 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 243 413 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 01 Early Periodic Screening, Diagnosis, and Treatment (EPSDT) or Child Health Assessment Program (CHAP) 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. CLM-19 1383 Predetermination of Benefits Code Identifier (ID) Optional Code identifying reason for claim submission PB Predetermination of Dental Benefits CLM-20 1514 Delay Reason Code Identifier (ID) Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 244 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 245 413 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 XX Variants (all may be used) DTP Date - Appliance Placement DTP Date - Repricer Received Date DTP Date - Service 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 246 413 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Appliance Placement To specify any or all of a date, a time, or a time period Usage notes Required when reporting the date orthodontic appliances were placed. 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 452 D8 XXXX Variants (all may be used) DTP Date - Accident DTP Date - Repricer Received Date DTP Date - Service 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 452 Appliance Placement 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 Orthodontic Banding 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 247 413 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 - Appliance Placement DTP Date - Service 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 248 413 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes Required when all of the services for this claim were performed. Not used when the claim is being submitted as a Predetermination of Benefits. 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 472 RD8 XX Variants (all may be used) DTP Date - Accident DTP Date - Appliance Placement 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 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. 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 249 413 DN1 1450 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DN1 Orthodontic Total Months of Treatment To supply orthodontic information Usage notes Required when the claim contains services related to treatment for orthodontic purposes. If not required by this implementation guide, do not send. When reporting this segment, at least one of DN101, DN102 or DN104 must be present. Example DN1 00 00000000000 XX Max use 1 Optional DN1-01 380 Orthodontic Treatment Months Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity DN101 is the estimated number of treatment months. DN1-02 380 Orthodontic Treatment Months Remaining Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity DN102 is the number of treatment months remaining. DN1-04 352 Orthodontic Treatment Indicator Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content DN104 is the appliance description. Usage notes The only allowed value for DN104 is "Y", which indicates that services reported on this claim are for orthodontic purposes and that both DN101 and DN102 were not submitted. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 250 413 DN2 1500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop DN2 Tooth Status To specify the status of individual teeth Usage notes Required when the submitter is reporting a missing tooth or a tooth to be extracted in the future. If not required by this implementation guide, do not send. Example DN2 XX E JP Max use 35 Optional DN2-01 127 Tooth 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 DN201 is the tooth number. Usage notes The Universal National Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association. DN2-02 1368 Tooth Status Code Identifier (ID) Required Code specifying the status of the tooth E To Be Extracted M Missing DN2-06 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list DN206 designates the code set used to identify the tooth in DN201. JP Universal National Tooth Designation System 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 251 413 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 P6 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 B4 Referral Form DA Dental Models DG Diagnostic Report EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) OZ Support Data for Claim P6 Periodontal Charts RB Radiology Films RR Radiology Reports 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 252 413 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 | /kaggle/input/edi-db-835-837/United Healthcare 837 Health Care Claim_ Dental.pdf | e52a8425126fbab9db1413c494cc97ed | e52a8425126fbab9db1413c494cc97ed_6 |
Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association. DN2-02 1368 Tooth Status Code Identifier (ID) Required Code specifying the status of the tooth E To Be Extracted M Missing DN2-06 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list DN206 designates the code set used to identify the tooth in DN201. JP Universal National Tooth Designation System 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 251 413 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 P6 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 B4 Referral Form DA Dental Models DG Diagnostic Report EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) OZ Support Data for Claim P6 Periodontal Charts RB Radiology Films RR Radiology Reports 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 252 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 253 413 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 03 000 0000 XXXXXX 000000 XXXX Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 254 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 255 413 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 000000000000 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 256 413 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 XX Variants (all may be used) REF Claim Identifier For Transmission Intermediaries REF Payer Claim Control Number REF Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 257 413 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 XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Payer Claim Control Number REF Predetermination Identification 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 258 413 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 Claim Identifier For Transmission Intermediaries REF Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 259 413 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop REF Predetermination Identification To specify identifying information Usage notes Required when sending the Predetermination of Benefits Identification Number for services that have been previously predetermined and are now being submitted for payment. If not required by this implementation guide, do not send. Reference numbers at this position apply to the entire claim. Example REF G3 XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries 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 G3 Predetermination of Benefits Identification Number REF-02 127 Predetermination of Benefits 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 260 413 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. 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. This segment must not be used to report the Predetermination of Benefits Identification Number. 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 G1 X Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Payer Claim Control Number REF Predetermination Identification 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 261 413 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 262 413 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. This segment must not be used to report the Predetermination of Benefits Identification Number. Example REF 9F XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Payer Claim Control Number REF Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 263 413 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 XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Payer Claim Control Number REF Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 264 413 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 XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Payer Claim Control Number REF Predetermination Identification 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 265 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 266 413 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. 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 ADD XXXX Max use 5 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 267 413 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. Required when the diagnosis may have an impact on the adjudication of the claim in cases where specific dental procedures may minimize the risks associated with the connection between the patient's oral and systemic health conditions. If not required by this implementation guide, do not send. Example HI TQ X ABF XXXX X XXXX XX XXXXX 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. 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 TQ Systemized Nomenclature of Dentistry (SNODENT) 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 SNODENT codes as an allowable code set under HIPAA, OR the Secretary of Health and Human Services grants an exception to use the code set as a pilot project. C022-02 1271 Principal 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 268 413 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 TQ Systemized Nomenclature of Dentistry (SNODENT) 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 SNODENT codes as an allowable code set under HIPAA, OR the Secretary of Health and Human Services grants an exception to use the code set as a pilot project. 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 Code List Qualifier Code Min 1 Max 3 Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. Usage notes 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 269 413 See element HI02-1 for a list of valid values. 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 Code List Qualifier Code Min 1 Max 3 Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. Usage notes See element HI02-1 for a list of valid values. 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 270 413 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 12 00000000000000 0000000 X 0000 XX T 3 3 2 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 271 413 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-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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 272 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 273 413 2310A Referring Provider Name Loop Max 2 Optional Variants (all may be used) Rendering Provider Name Loop Service Facility Location Name Loop Assistant Surgeon Name Loop Supervising Provider 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 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 the 2310A loop at the claim 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. Example NM1 DN 1 XXX XXX X 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 274 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 275 413 PRV 2550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop PRV Referring 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 RF PXC XXXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider RF Referring 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 276 413 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 0B 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 277 413 2310B Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Service Facility Location Name Loop Assistant Surgeon Name Loop Supervising 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 NM1 information is different than that carried in the Billing Provider loop (Loop ID-2010AA) and the Assistant Surgeon loop (Loop ID- 2310D) is not used. 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 X XXXXX X 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 278 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 279 413 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 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 Required 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 280 413 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 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 281 413 2310C Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Referring Provider Name Loop Rendering Provider Name Loop Assistant Surgeon Name Loop Supervising 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. When the service(s) was rendered in the patient's home (the address reported as the patient address in the Subscriber or Patient loop), do not use the Service Facility Location loop. In that case, the place of service code in CLM05-1 indicates that the service occurred in the patient's home. The purpose of this loop is to identify specifically where the service was rendered. 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 X 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 282 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 283 413 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 XXX XX 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 284 413 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 XXXXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 285 413 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 286 413 2310C 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 287 413 2310D Assistant | /kaggle/input/edi-db-835-837/United Healthcare 837 Health Care Claim_ Dental.pdf | e52a8425126fbab9db1413c494cc97ed | e52a8425126fbab9db1413c494cc97ed_7 |
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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 285 413 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 286 413 2310C 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 287 413 2310D Assistant Surgeon Name 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 NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Assistant Surgeon Name Loop NM1 Assistant Surgeon Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider provided these services in the role of the Assisting Surgeon. 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 DD 1 XX XXX XX XXXXX XX XXX If either Identification Code Qualifier (NM1-08) or Assistant Surgeon 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 DD Assistant Surgeon NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Assistant Surgeon Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Assistant Surgeon First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 288 413 Individual first name NM1-05 1037 Assistant Surgeon Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Assistant Surgeon 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) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Assistant Surgeon Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 289 413 PRV 2550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Assistant Surgeon Name Loop PRV Assistant Surgeon Specialty Information To specify the identifying characteristics of a provider Usage notes 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 PRV AS PXC XXXXXX Max use 1 Required PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider AS Assistant Surgeon 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 290 413 2310D Assistant Surgeon Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Assistant Surgeon Name Loop REF Assistant Surgeon 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 Assistant Surgeon 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 291 413 2310E 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 Assistant Surgeon Name 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 or dentist. 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 X XX XXXXX 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 Use this code for the supervising dentist or 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 292 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 293 413 2310E 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 when the HIPAA National Provider Identifier (NPI) is not reported in NM109 of this loop; OR Required for Health Care Providers prior to the mandated NPI implementation date when an NPI is reported in NM109 of this loop and an additional identification number is required by the receiver to identify the provider; OR Required for providers who are not Health Care Providers when an NPI is reported in NM109 of this loop and an additional identification number is required by 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 294 413 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 H 20 XXXXX XXXXXX 13 BL 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 295 413 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) Optional 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 296 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 297 413 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 00000000000 000000000000 XXXXX 000000 00 0000 X 0 0000000000 XXXX 0000 0000000 XX 0000 000 000000000 XXXX 00000000000000 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 298 413 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 299 413 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 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 300 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 301 413 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 000000000000000 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 302 413 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 000000 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 303 413 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 304 413 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 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 element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. This is a crosswalk from CLM08 when doing COB. 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 The Release of Information response is limited to the information carried in this claim. This is a crosswalk from CLM09 when doing COB. 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 305 413 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 0000000000 000 X XXXX XXXX XXXXXX XXX 000000 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 306 413 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-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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 307 413 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 Supervising Provider Loop Other Payer Billing Provider Loop Other Payer Service Facility Location Loop Other Payer Assistant Surgeon 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 XXX X XXXXXX XXXX II 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 308 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 309 413 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 XX XXXXXX 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 310 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 311 413 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 312 413 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 X 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 313 413 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 Supervising Provider Loop Other Payer Billing Provider Loop Other Payer Service Facility Location Loop Other Payer Assistant Surgeon 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 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 314 413 On or after the mandated implementation date for the HIPAA National Plan Identifier (National Plan ID), XV must be sent. Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent. If a phase-in period is designated, PI must be sent unless: Both the sender and receiver agree to use the National Plan ID, The receiver has a National Plan ID, and The sender has the capability to send the National Plan ID. If all of the above conditions are true, XV must be sent. In this case the Payer Identification Number that would have been sent using qualifier PI can be sent in the corresponding REF segment using qualifier 2U. 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 315 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 316 413 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 317 413 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 318 413 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 X 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 319 413 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 Predetermination Identification 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 320 413 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 Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 321 413 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 Predetermination Identification To specify identifying information Usage notes Required when the payer identified in this loop has assigned a predetermination identification number to this claim. If not required by this implementation guide, do not send. Example REF G3 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 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 G3 Predetermination of Benefits Identification Number REF-02 127 Other Payer Predetermination of Benefits 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 322 413 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 This | /kaggle/input/edi-db-835-837/United Healthcare 837 Health Care Claim_ Dental.pdf | e52a8425126fbab9db1413c494cc97ed | e52a8425126fbab9db1413c494cc97ed_8 |
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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 320 413 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 Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 321 413 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 Predetermination Identification To specify identifying information Usage notes Required when the payer identified in this loop has assigned a predetermination identification number to this claim. If not required by this implementation guide, do not send. Example REF G3 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 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 G3 Predetermination of Benefits Identification Number REF-02 127 Other Payer Predetermination of Benefits 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 322 413 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 This segment must not be used to report the Predetermination of Benefits Identification Number. 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 Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 323 413 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 Predetermination Identification 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 324 413 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 prior to the mandated implementation date for the HIPAA National Plan Identifier when an additional identification number to that provided in the 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 2U XXXXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Predetermination Identification REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 325 413 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 Supervising Provider Loop Other Payer Billing Provider Loop Other Payer Service Facility Location Loop Other Payer Assistant Surgeon 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 326 413 1 Person 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 327 413 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 See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF 1G 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. REF-02 127 Other Payer Referring 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 328 413 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 Supervising Provider Loop Other Payer Billing Provider Loop Other Payer Service Facility Location Loop Other Payer Assistant Surgeon 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 329 413 1 Person 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 330 413 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 See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF G2 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. 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 331 413 2330E 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 Billing Provider Loop Other Payer Service Facility Location Loop Other Payer Assistant Surgeon 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 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 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 Use this code for the supervising dentist or physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 332 413 1 Person 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 333 413 2330E 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 Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 334 413 2330F 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 Supervising Provider Loop Other Payer Service Facility Location Loop Other Payer Assistant Surgeon 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 335 413 1 Person 2 Non-Person Entity 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 336 413 2330F Other Payer Billing 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 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 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 337 413 2330G 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 Other Payer Assistant Surgeon 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 338 413 2 Non-Person Entity 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 339 413 2330G 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 LU 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 340 413 2330H Other Payer Assistant Surgeon 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 Other Payer Service Facility Location 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 Assistant Surgeon Loop NM1 Other Payer Assistant Surgeon 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 DD 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 DD Assistant Surgeon NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 341 413 1 Person 2 Non-Person Entity 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 342 413 2330H Other Payer Assistant Surgeon 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 Assistant Surgeon Loop REF Other Payer Assistant Surgeon Secondary Identifier To specify identifying information Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example REF LU 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. LU Location Number REF-02 127 Other Payer Assistant Surgeon 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 343 413 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 344 413 SV3 3800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop SV3 Dental Service To specify the service line item detail for dental work Example SV3 AD XXXX XX XX XX XX XXX 0000000000000 XX X X X XX X XXX R 00000 00 00 00 0 Max use 1 Required SV3-01 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. AD American Dental Association Codes CDT Current Dental Terminology 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. Usage notes A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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. Usage notes 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 345 413 A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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 A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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. Usage notes A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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. SV3-02 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SV302 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. SV3-03 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. SV303 is the place of service code representing the location where the dental treatment was rendered. Usage notes 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 346 413 See CODE SOURCE 237: Place of Service Codes for Professional Claims SV3-04 C006 Oral Cavity Designation To identify one or more areas of the oral cavity Usage notes Required when the nomenclature associated with the procedure reported in SV301-2 refers to quadrant or arch and the area of the oral cavity is not uniquely defined by the procedure description. Report individual tooth numbers in one or more TOO segments. Max use 1 Optional C006-01 1361 Oral Cavity Designation Code Min 1 Max 3 Identifier (ID) Required Code Identifying the area of the oral cavity in which service is rendered C006-02 1361 Oral Cavity Designation Code Min 1 Max 3 Identifier (ID) Optional Code Identifying the area of the oral cavity in which service is rendered C006-03 1361 Oral Cavity Designation Code Min 1 Max 3 Identifier (ID) Optional Code Identifying the area of the oral cavity in which service is rendered C006-04 1361 Oral Cavity Designation Code Min 1 Max 3 Identifier (ID) Optional Code Identifying the area of the oral cavity in which service is rendered C006-05 1361 Oral Cavity Designation Code Min 1 Max 3 Identifier (ID) Optional Code Identifying the area of the oral cavity in which service is rendered SV3-05 1358 Prosthesis, Crown, or Inlay Code Identifier (ID) Optional Code specifying the placement status for the dental work I Initial Placement R Replacement When SV305 R, then the DTP segment in the 2400 loop for Prior Placement is Required. SV3-06 380 Procedure Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity SV306 is the number of procedures. Usage notes 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 347 413 Number of procedures SV3-11 C004 Composite Diagnosis Code Pointer To identify one or more diagnosis code pointers Usage notes Required when the service relates to that specific diagnosis and is needed to substantiate the medical treatment. If not required by this implementation guide, do not send. Max use 1 Optional 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. 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. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 348 413 TOO 3820 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop TOO Tooth Information To identify a tooth by number and, if applicable, one or more tooth surfaces Usage notes Required when reporting tooth information related to this service line. If not required by this implementation guide, do not send. Multiple iterations of the TOO segment are allowed only when the quantity reported in Loop ID-2400 SV306 is equal to one. Example TOO JP XX I XX X XX XX Max use 32 Optional TOO-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list JP Universal National Tooth Designation System TOO-02 1271 Tooth Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list Usage notes See Appendix A for code source 135: American Dental Association Codes. This element may only be used to report individual teeth. It may not be used to report areas of the oral cavity such as quadrants or sextants. Areas of the oral cavity must be reported in one or more of the components of SV304. TOO-03 C005 Tooth Surface To identify one or more tooth surface codes Usage notes Required when the procedure code requires tooth surface codes. If not required by this implementation guide, do not send. Max use 1 Optional C005-01 1369 Tooth Surface Code Identifier (ID) Required Code identifying the area of the tooth that was treated 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 349 413 B Buccal D Distal F Facial I Incisal L Lingual M Mesial O Occlusal C005-02 1369 Tooth Surface Code Min 1 Max 2 Identifier (ID) Optional Code identifying the area of the tooth that was treated Usage notes Additional tooth surface codes can be carried in TOO03-2 through TOO03-5. The code values are the same as in TOO03-1. C005-03 1369 Tooth Surface Code Min 1 Max 2 Identifier (ID) Optional Code identifying the area of the tooth that was treated C005-04 1369 Tooth Surface Code Min 1 Max 2 Identifier (ID) Optional Code identifying the area of the tooth that was treated C005-05 1369 Tooth Surface Code Min 1 Max 2 Identifier (ID) Optional Code identifying the area of the tooth that was treated 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 350 413 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 - Appliance Placement To specify any or all of a date, a time, or a time period Usage notes Required when the orthodontic appliance placement date is different than the orthodontic appliance placement date in the DTP segment in the Loop ID-2300 loop. If not required by this implementation guide, do not send.; Example DTP 452 D8 XXXX Variants (all may be used) DTP Date - Prior Placement DTP Date - Replacement DTP Date - Service Date DTP Date - Treatment Completion DTP Date - Treatment Start 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 452 Appliance Placement 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 Orthodontic Banding 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 351 413 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 - Prior Placement To specify any or all of a date, a time, or a time period Usage notes Required when the value of SV305 for this iteration of the 2400 loop is R - Replacement. If not required by this implementation guide, do not send. Example DTP 441 D8 XXXX Variants (all may be used) DTP Date - Appliance Placement DTP Date - Replacement DTP Date - Service Date DTP Date - Treatment Completion DTP Date - Treatment Start 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 139 Estimated Required when the exact Prior Placement Date is not known. 441 Prior Placement Required when the exact Prior Placement Date is known. 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 Prior Placement 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 352 413 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 - Replacement To specify any or all of a date, a time, or a time period Usage notes Required when reporting the date that an orthodontic appliance was replaced. If not required by this implementation guide, do not send. Example DTP 446 D8 XXXXX Variants (all may be used) DTP Date - Appliance Placement DTP Date - Prior Placement DTP Date - Service Date DTP Date - Treatment Completion DTP Date - Treatment Start 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 446 Replacement 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 Replacement 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 353 413 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 when the service was performed and the service date is different than the date reported in the Service Date segment in the 2300 loop. If not required by this implementation guide, do not send. Do not use this DTP segment when submitting a Predetermination of Dental Benefits. Do not use this DTP segment when submitting a Treatment Start Date, Treatment Completion Date or both. Example DTP 472 D8 XX Variants (all may be used) DTP Date - Appliance Placement DTP Date - Prior Placement DTP Date - Replacement DTP Date - Treatment Completion DTP Date - Treatment Start 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. D8 Date Expressed in Format 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 354 413 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 - Treatment Completion To specify any or all of a date, a time, or a time period Usage notes Required when reporting the date that a course of treatment was completed. If not required by this implementation guide, do not send. When the Treatment Completion Date is used, the Date of Service must not be used. Example DTP 198 D8 XXXX Variants (all may be used) DTP Date - Appliance Placement DTP Date - Prior Placement DTP Date - Replacement DTP Date - Service Date DTP Date - Treatment Start 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 198 Completion 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 Completion 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 355 413 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 - Treatment Start To specify any or all of a date, a time, or a time period Usage notes Required when reporting initial impression or preparation for a crown or denture. OR Required when reporting initial endodontic treatment. OR Required when reporting the implant fixture placement. If not required by this implementation guide, do not send. When the Treatment Start Date is used, the Date of Service must not be used. Example DTP 196 D8 XX Variants (all may be used) DTP Date - Appliance Placement DTP Date - Prior Placement DTP Date - Replacement DTP Date - Service Date DTP Date - Treatment Completion 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 196 Start 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 Start 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 356 413 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 03 00000000000000 00 X 00 XXXXX Max use 1 Optional CN1-01 1166 Contract Type Code Identifier (ID) Required Code identifying a contract type 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 357 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 358 413 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 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 Line Item Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 359 413 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 XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Prior Authorization REF Referral | /kaggle/input/edi-db-835-837/United Healthcare 837 Health Care Claim_ Dental.pdf | e52a8425126fbab9db1413c494cc97ed | e52a8425126fbab9db1413c494cc97ed_9 |
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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 357 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 358 413 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 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 Line Item Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 359 413 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 XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Predetermination 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 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 360 413 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 This segment must not be used to report the Predetermination of Benefits Identification Number. 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 XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Line Item Control Number REF Referral Number REF Repriced Claim Number REF Service Predetermination Identification 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 361 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 362 413 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 XXXXX 2U XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Line Item Control Number REF Prior Authorization REF Repriced Claim Number REF Service Predetermination Identification 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 363 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 364 413 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 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 XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Line Item Control Number REF Prior Authorization REF Referral Number REF Service Predetermination Identification 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 365 413 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Service Predetermination Identification To specify identifying information Usage notes Required when sending the Predetermination of Benefits Identification Number for the line item that has been previously predetermined and is now being submitted for payment. If not required by this implementation guide, do not send. Reference numbers at this position apply to the current line item only. 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 G3 X 2U XXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Line Item Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G3 Predetermination of Benefits Identification Number REF-02 127 Predetermination of Benefits 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 Predetermination Identification 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 366 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 367 413 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 (SV302) for this service line must include the amount reported in the Sales Tax Amount. Example AMT T 0000 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 368 413 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 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 369 413 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 09 00000000000 000 XXX 000 AD XXXXX UN 000 0 T1 5 3 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 370 413 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-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) AD American Dental Association Codes 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 371 413 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 5 State Mandates 6 Other 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 372 413 2420A Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Assistant Surgeon Name Loop Supervising Provider Name Loop Service Facility Location 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 the Rendering Provider NM1 information is different than that carried in the Loop ID-2310B Rendering Provider and the Assistant Surgeon (Loop ID-2420C) loop is not present OR Required when each of the following conditions apply: the Rendering Provider information is carried at the Billing Provider level (Loop ID- 2010AA) this particular line item has different Rendering Provider information than that which is carried in the Loop ID-2010AA Billing Provider the Assistant Surgeon loop (Loop ID-2420C) is not used. 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. Example NM1 82 2 XXXXX XXXXX XXXXXX 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 2 Non-Person Entity 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 373 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 374 413 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 Example PRV PE PXC XXX Max use 1 Required 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 375 413 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 1G 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 376 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 377 413 2420B Assistant Surgeon Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Supervising Provider Name Loop Service Facility Location 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 Assistant Surgeon Name Loop NM1 Assistant Surgeon Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider provided these services in the role of the Assistant Surgeon and the Assistant Surgeon information in this loop is different from the Assistant Surgeon information sent in Loop ID-2310D. If not required by this implementation guide, do not send.; Example NM1 DD 1 XXXXXX XX XXX X XX XXXXXX If either Identification Code Qualifier (NM1-08) or Assistant Surgeon 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 DD Assistant Surgeon NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Assistant Surgeon Last or Organization Name String (AN) Required Min 1 Max 60 Individual last name or organizational name NM1-04 1036 Assistant Surgeon First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 378 413 Individual first name NM1-05 1037 Assistant Surgeon Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial NM1-07 1039 Assistant Surgeon 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 Assistant Surgeon Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 379 413 PRV 5050 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Assistant Surgeon Name Loop PRV Assistant Surgeon Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the Assistant Surgeon specialty information is needed to facilitate reimbursement of the claim. If not required by this implementation guide, do not send.; Example PRV AS PXC XXXXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider AS Assistant Surgeon 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 380 413 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Patient Hierarchical Level Loop Claim Information Loop Service Line Number Loop Assistant Surgeon Name Loop REF Assistant Surgeon 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 send provider identifiers that are not payer-specific (e.g. UPIN, State License Number), those identifiers must be sent in the corresponding 2310 loop. 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. LU Location Number REF-02 127 Assistant Surgeon 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 Max use 1 Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 381 413 2420B Assistant Surgeon 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 382 413 2420C Supervising Provider Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Assistant Surgeon Name Loop Service Facility Location 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 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 or dentist and the supervising physician or dentist 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 XXX XXXXX X XX XX 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 Use this code for the supervising dentist or 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 383 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 384 413 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 this segment is used, the identifier(s) to be provided are limited to those necessary for the claim processor to identify the entity. 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 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 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 Max use 1 Optional 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 385 413 2420C Supervising 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 386 413 2420D Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Rendering Provider Name Loop Assistant Surgeon Name Loop Supervising 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 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. 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 387 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 388 413 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 XXXXX X 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 389 413 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 XXXX XX XXXXXX 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 390 413 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 391 413 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 XXX 2U X Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 392 413 2420D Service Facility Location 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 393 413 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 0000000000 ER XXXXX XX XX XX XX XXX 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. Max use 1 Required C003-01 235 Product or Service ID Qualifier Identifier (ID) Required 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 394 413 Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply 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. Usage notes This is the first procedure code modifier. A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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. Usage notes This is the second procedure code modifier. A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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 This is the third procedure code modifier. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 395 413 A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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. Usage notes This is the fourth procedure code modifier. A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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 | /kaggle/input/edi-db-835-837/United Healthcare 837 Health Care Claim_ Dental.pdf | e52a8425126fbab9db1413c494cc97ed | e52a8425126fbab9db1413c494cc97ed_10 |
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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 394 413 Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. AD American Dental Association Codes ER Jurisdiction Specific Procedure and Supply 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. Usage notes This is the first procedure code modifier. A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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. Usage notes This is the second procedure code modifier. A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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 This is the third procedure code modifier. 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 395 413 A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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. Usage notes This is the fourth procedure code modifier. A modifier must be from code source 135 (American Dental Association) found in the Code on Dental Procedures and Nomenclature'. 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 396 413 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 XXXX 000000000000 000 XX 00000000000000 00 00000000000 X 00 000000000000000 XXXXX 000000000 0 0000000000 XXXXX 0000000000 00 XXXXX 000000 000 0000000000 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 397 413 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 398 413 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 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 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 399 413 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 400 413 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 XXX 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 401 413 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 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. 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 not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Example AMT EAF 00000 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 402 413 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 0000000000 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 403 413 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 0000 0 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 United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 404 413 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, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 405 413 EDI Samples Example 1: Commercial Health Insurance ST 837 3456 005010X224A3 BHT 0019 00 0123 20061123 1023 31 NM1 41 2 PREMIER BILLING SERVICE 46 TGJ23 PER IC JERRY TE 7176149999 NM1 40 2 INSURANCE COMPANY XYZ 46 66783JJT HL 1 20 1 NM1 85 2 DENTAL ASSOCIATES XX 1234567890 N3 234 SEAWAY ST N4 MIAMI FL 33111 REF EI 587654321 HL 2 1 22 1 SBR P CI NM1 IL 1 SMITH JANE MI 111223333 NM1 PR 2 INSURANCE COMPANY XYZ PI 66783JJT HL 3 2 23 0 PAT 19 NM1 QC 1 SMITH TED N3 236 N MAIN ST N4 MIAMI FL 33413 DMG D8 19920501 M CLM 26403774 150 11 B 1 Y A Y I DTP 472 D8 20061029 REF D9 17312345600006351 NM1 82 1 KILDARE BEN XX 9876543210 PRV PE PXC 1223G0001X LX 1 SV3 AD D2150 100 1 TOO JP 12 M O LX 2 SV3 AD D1110 50 1 SE 31 3456 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 406 413 Example 2a: Claim From Billing Provider to Payer A ST 837 0002 005010X224A3 BHT 0019 00 0123 20061123 1023 31 NM1 41 2 PREMIER BILLING SERVICE 46 567890 PER IC JERRY TE 7176149999 NM1 40 2 KEY INSURANCE COMPANY 46 999996666 HL 1 20 1 NM1 85 2 DENTAL ASSOCIATES XX 4567890123 N3 234 SEAWAY ST N4 MIAMI FL 33111 REF EI 587654321 HL 2 1 22 1 SBR P CI NM1 IL 1 SMITH JANE MI JS00111223333 NM1 PR 2 KEY INSURANCE COMPANY PI 999996666 HL 3 2 23 0 PAT 19 NM1 QC 1 SMITH TED N3 236 N MAIN ST N4 MIAMI FL 33413 DMG D8 19920501 M CLM 26403774 200 11 B 1 Y A Y I DTP 472 D8 20061109 REF D9 111222333444 NM1 82 1 KILDARE BEN XX 6789012345 PRV PE PXC 1223P0221X LX 1 SV3 AD D3320 200 1 TOO JP 5 SE 29 0002 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 407 413 Example 2b: Claim from Billing Provider to Payer B ST 837 0123 005010X224A3 BHT 0019 00 0123 20061123 1023 31 NM1 41 2 PREMIER BILLING SERVICE 46 567890 PER IC JERRY TE 7176149999 NM1 40 2 GREAT PRAIRIES HEALTH 46 123456789 HL 1 20 1 NM1 85 2 DENTAL ASSOCIATES XX 4567890123 N3 234 SEAWAY ST N4 MIAMI FL 33111 REF EI 587654321 HL 2 1 22 1 SBR S CI NM1 IL 1 SMITH JACK MI T55TY666 NM1 PR 2 GREAT PRAIRIES HEALTH PI 123456789 HL 3 2 23 0 PAT 19 NM1 QC 1 SMITH TED N3 236 N MAIN ST N4 MIAMI FL 33413 DMG D8 19920501 M CLM 26403774 200 11 B 1 Y A Y I DTP 472 D8 20061109 REF D9 444333222111 NM1 82 1 KILDARE BEN XX 6789012345 PRV PE PXC 1223P0221X SBR P 19 CI CAS PR 1 50 1 AMT D 150 OI Y I NM1 IL 1 SMITH JANE MI JS00111223333 N3 236 N MAIN ST N4 MIAMI FL 33413 NM1 PR 2 KEY INSURANCE COMPANY PI 999996666 DTP 573 D8 20061122 LX 1 SV3 AD D3320 200 1 TOO JP 5 SE 38 0123 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 408 413 Example 3: Predetermination of Benefits ST 837 0321 005010X224A3 BHT 0019 00 0123 20061123 1023 31 NM1 41 2 ABC CLEARINGHOUSE 46 ABC123 PER IC JERRY TE 7176149999 NM1 40 2 KEY INSURANCE COMPANY 46 999996666 HL 1 20 1 PRV BI PXC 1223G0001X NM1 85 1 JOHN DOE XX 2345678901 N3 123 TOOTH DRIVE N4 MIAMI FL 33411 REF EI 587654321 HL 2 1 22 0 SBR P 18 CI NM1 IL 1 SMITH JANE MI 111223333 N3 236 N MAIN ST N4 MIAMI FL 33413 DMG D8 19430501 F NM1 PR 2 KEY INSURANCE COMPANY PI 999996666 CLM SMITH878 750 11 B 1 Y A Y I PB PWK RB BM AC SMITHJANE11122333 REF D9 123123123 LX 1 SV3 AD D2750 750 I 1 TOO JP 13 SE 25 0321 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 409 413 Example 4: Orthodontic Treatment Plan ST 837 0322 005010X224A3 BHT 0019 00 0123 20061123 1023 31 NM1 41 2 JOHN DOE 46 940001 PER IC SALLY TE 7175555555 NM1 40 2 KEY INSURANCE COMPANY 46 999996666 HL 1 20 1 PRV BI PXC 1223G0001X NM1 85 1 JOHN DOE XX 2345678901 N3 123 TOOTH DRIVE N4 MIAMI FL 33411 REF EI 587654321 HL 2 1 22 1 SBR P CI NM1 IL 1 SMITH JANE MI 111223333 NM1 PR 2 KEY INSURANCE COMPANY PI 999996666 HL 3 2 23 0 PAT 19 NM1 QC 1 SMITH TED N3 236 N MAIN ST N4 MIAMI FL 33413 DMG D8 19911029 M CLM SMITH788 4000 11 B 1 Y A Y I DTP 452 D8 20061115 DN1 36 LX 1 SV3 AD D8080 4000 1 SE 27 0322 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 410 413 Example 5: Sales Tax ST 837 0001 005010X224A3 BHT 0019 00 1000002 20140305 0745 31 NM1 41 2 XYZ CLEARINGHOUSE 46 321123 PER IC XYZ CLEARINGHOUSE, INC. TE 8005551212 EX 123 EM PRODUCTIONSUPPORT XYZCLEARINGHOUSE.COM NM1 40 2 ACME DENTAL PAYER 46 12345 HL 1 20 1 NM1 85 2 ANYTOWN DENTAL XX 1234567984 N3 926 MAIN ST N4 ANYTOWN FL 327147244 REF EI 222222222 PER IC ANYTOWN DENTAL TE 4075551213 HL 2 1 22 0 SBR P 18 12345687 CI NM1 IL 1 SUBLAST SUBFIRST M MI 123456 N3 654 ANYWHERE DR N4 ANYTOWN FL 32000 DMG D8 19710101 M NM1 PR 2 BLUE EXAMPLE PI 11111 CLM 119033233 293.19 11 B 1 Y C Y Y PWK OZ EL AC NEA123456798 REF D9 0001958960000001 NM1 82 1 RENDERLAST RENDERFIRST XX 1234567893 PRV PE PXC 1223G0001X LX 1 SV3 AD D7140 150 TOO JP 31 REF 6R 01 LX 2 SV3 AD D0140 130 REF 6R 02 LX 3 SV3 AD D9985 13.19 REF 6R 03 SE 34 0001 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 411 413 Example 6: Multiple Tooth Numbers ST 837 0001 005010X224A3 BHT 0019 00 1000002 20140305 0745 31 NM1 41 2 XYZ CLEARINGHOUSE 46 321123 PER IC XYZ CLEARINGHOUSE, INC. TE 8005551212 EX 123 EM PRODUCTIONSUPPORT XYZCLEARINGHOUSE.COM NM1 40 2 ACME DENTAL PAYER 46 12345 HL 1 20 1 NM1 85 2 ANYTOWN DENTAL XX 1234567984 N3 926 MAIN ST N4 ANYTOWN FL 327147244 REF EI 222222222 PER IC ANYTOWN DENTAL TE 4075551213 HL 2 1 22 0 SBR P 18 12345687 CI NM1 IL 1 SUBLAST SUBFIRST M MI 123456 N3 654 ANYWHERE DR N4 ANYTOWN FL 32000 DMG D8 19710101 M NM1 PR 2 ACME DENTAL PAYER PI 11111 CLM 1191 900 11 B 1 Y C Y Y PWK OZ EL AC NEA123456798 REF D9 0001958960000001 NM1 82 1 RENDERLAST RENDERFIRST XX 1234567893 PRV PE PXC 1223G0001X LX 1 SV3 AD D5214 900 TOO JP 31 TOO JP 30 TOO JP 21 TOO JP 19 TOO JP 18 SE 31 0001 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 412 413 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 7: Quantity Greater Than 1 ST 837 0001 005010X224A3 BHT 0019 00 1000002 20140305 0745 31 NM1 41 2 XYZ CLEARINGHOUSE 46 321123 PER IC XYZ CLEARINGHOUSE, INC. TE 8005551212 EX 123 EM PRODUCTIONSUPPORT XYZCLEARINGHOUSE.COM NM1 40 2 ACME DENTAL PAYER 46 12345 HL 1 20 1 NM1 85 2 ANYTOWN DENTAL XX 1234567984 N3 926 MAIN ST N4 ANYTOWN FL 327147244 REF EI 222222222 PER IC ANYTOWN DENTAL TE 4075551213 HL 2 1 22 0 SBR P 18 12345687 CI NM1 IL 1 SUBLAST SUBFIRST M MI 123456 N3 654 ANYWHERE DR N4 ANYTOWN FL 32000 DMG D8 19710101 M NM1 PR 2 BLUE EXAMPLE PI 11111 CLM 22 44 11 B 1 Y C Y Y DTP 472 D8 20140303 REF D9 0001958960000001 HI BK 5273 NM1 82 1 RENDERLAST RENDERFIRST XX 1234567893 PRV PE PXC 1223G0001X REF 0B 321654 LX 1 SV3 AD D0230 44 I 4 REF 6R 123456-01 SE 29 0001 1 30 25, 11:54 AM United Healthcare 837 Health Care Claim: Dental (X224A3) - Stedi EDI Guides https: www.stedi.com app guides view united-healthcare health-care-claim-dental-x224a3 01H16GMNR82AHJ33K66ZM6FZ1F 413 413 | /kaggle/input/edi-db-835-837/United Healthcare 837 Health Care Claim_ Dental.pdf | e52a8425126fbab9db1413c494cc97ed | e52a8425126fbab9db1413c494cc97ed_11 |
Healthcare and Family Services, Bureau of Information Services HIPAA 5010 - Health Care Claim Payment Advice (835) Standard Companion Guide Instructions related to Transactions based on ASC X12 Implementation Guide version 005010X221 and the ERRATA 005010X221A1 dated June 2010 1 005010 December 2011 (WEDI) and the Data Interchange Standards Association (DISA), on behalf of the Accredited Standards Committee (ASC) X12. 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 2011 Companion Guide copyright by the Illinois Department of Healthcare and Family Services. This template is Copyright 2010 by The Workgroup for Electronic Data Interchange Companion Guide Version Number: 1.0 5 3 8 2 005010 December 2011 Preface Companion Guides (CG) may contain two types of data, instructions for electronic communications with the publishing entity (Communications Connectivity Instructions) and supplemental information for creating transactions for the publishing entity while ensuring compliance with the associated ASC X12 IG (Transaction Instructions). Either the Communications Connectivity component or the Transaction Instruction component must be included in every CG. The components may be published as separate documents or as a single document. The Communications Connectivity component is included in the CG when the publishing entity wants to convey the information needed to commence and maintain communication exchange. The Transaction Instruction component is included in the CG when the publishing entity wants to clarify the IG instructions for submission of specific electronic transactions. The Transaction Instruction component content is limited by ASCX12 s copyrights and Fair Use statement. 3 005010 December 2011 Table of Contents 1 TI Introduction.......................................................................................................... 5 1.1 Background...................................................................................................................5 1.1.1 Overview of HIPAA Legislation........................................................................... 5 1.1.2 Compliance according to HIPAA......................................................................... 5 1.1.3 Compliance according to ASC X12..................................................................... 6 1.2 Intended Use.................................................................................................................6 2 Included ASC X12 Implementation Guides............................................................ 6 4 TI Additional Information...................................................................................... 14 4.1 Payer Specific Business Rules and Limitations...........................................................14 4.2 Claim Overpayment and Recovery..............................................................................18 5 TI Change Summary.............................................................................................. 22 7.................................................................................................... Instruction Tables 3 4 005010 December 2011 Transaction Instruction (TI) TI Introduction Background Overview of HIPAA Legislation The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carries provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard HIPAA serves to: Create better access to health insurance Limit fraud and abuse Reduce administrative costs Compliance according to HIPAA The HIPAA regulations at 45 CFR 162.915 require that covered entities not enter into a trading partner agreement that would do any of the following: Change the definition, data condition, or use of a data element or segment in a standard. Add any data elements or segments to the maximum defined data set. Use any code or data elements that are marked not used in the standard s implementation specifications or are not in the standard s implementation specification(s). Change the meaning or intent of the standard s implementation specification(s). 1.1.2 1.1.1 1.1 1 5 005010 December 2011 Compliance according to ASC X12 ASC X12 requirements include specific restrictions that prohibit trading partners from: Modifying any defining, explanatory, or clarifying content contained in the implementation guide. Modifying any requirement contained in the implementation guide. Intended Use The Transaction Instruction component of this companion guide must be used in conjunction with ASC X12 005010X221 Healthcare Claim Payment Advice (835) and the ERRATA 005010X221A1 dated June 2010. The instructions in this companion guide are not intended to be stand-alone requirements documents. This companion guide conforms to all the requirements of any associated ASC X12 Implementation Guides and is in conformance with ASC X12 s Fair Use and Copyright statements. Included ASC X12 Implementation Guides This table lists the X12N Implementation Guides for which specific transaction Instructions apply and which are included in Section 3 of this document. Unique ID Name 005010X221 005010X221A1 Health Care Claim Payment Advice (835) A1 ERRATA Healthcare Claim Payment Advice. 2 1.2 1.1.3 6 005010 December 2011 Instruction Tables These tables contain one or more rows of each segment for which a supplemental instruction is needed. Legend SHADED rows represent segments in the X12N implementation guide. NON-SHADED rows represent data elements in the X12N implementation guide. HFS Unique 835 Items 005010X221A1 Health Care Claim Payment Advice (835) Loop ID Reference Name Codes Notes Comments Header BPR Financial Information Header BPR02 Monetary amount Will represent the full payment amount for the Payee Header BPR04 Payment Method Code Refer to section 4.1 Header BPR10 FEIN Originating Company Identifier If payment balance is zero, this will be 1371320118. If payment is issued this will be 1376002057 3 7 005010 December 2011 Header TRN Reassociation Trace Number Header TRN02 Reference Identification Will represent the Check Warrant Number appended to Voucher Number Header DTM Production Date Header DTM02 Date Will represent Schedule Date (from Julian date in Voucher Number) 1000A N1 Payer Identification 1000A N102 Name ILLINOIS MEDICAID, ILLINOIS COMPTROLLE R If the payment balance is zero, this will be ILLINOIS MEDICAID. If the payment is issued, this will be ILLINOIS COMPTROLLER 1000B N1 Payee Identification 1000B N103 Identification Code Qualifier FI Will be FI 1000B N3 Payee Address Notes Comments Codes Name Reference Loop ID 8 005010 December 2011 1000B N301 Address Information 201 SOUTH GRAND AVENUE EAST, 325 WEST ADAMS ST If the payment balance is zero, this will be 201 SOUTH GRAND AVENUE EAST. If payment is issued, this will be 325 WEST ADAMS ST 1000B N4 Payee City, State, Zip Code 1000B N401 City Name SPRINGFIELD Will be SPRINGFIELD 1000B N402 State or Province Code IL Will be IL 1000B N403 Postal Code 62763, 627041871 If the payment balance is zero, this will be 627630001. If the payment is issued, this will be 627041871 2000 TS3 Provider Summary Information 2000 TS302 Facility Code Value For Professional Claims (837P), HFS will report code 11 (office) as place of Notes Comments Codes Name Reference Loop ID 9 005010 December 2011 service, if the 837P contains more than one value. For Long Term Care Claims, HFS will report code 11. For Institutional Claims (837I), HFS will report the first two-bytes of the bill type code. For Pharmaceutical Claims, the code will be 99 (other). 2100 CLP Claim Payment Information 2100 CLP02 Claim Status Code 1, 2, 3, 4, 22 Will be 1, 2, 3, 4 or 22. 2100 CLP03 Monetary Amount Will be the total billed amount 2100 CLP04 Monetary Amount Will be total paid amount 2100 CLP06 Claim Filing Indicator Code MC Will be MC 2100 CLP07 Reference Identification Will be the Document Control Number (DCN) 2100 CLP08 Facility Value This is the first 2- Notes Comments Codes Name Reference Loop ID 10 005010 December 2011 Code bytes of the Bill Type Code 2100 CAS Claim Adjustment 2100 CAS01 Claim Adjustment Group Code PR, CO, OA Will be PR, CO or OA 2100 NM1 Patient Name 2100 NM103 Name Last or Organization Name Will be Recipient s Last Name 2100 NM104 Name First Will be Recipient s First Name 2100 NM108 Identification Code Qualifier Will be MR 2100 NM1 Corrected Patient Insured Name 2100 NM102 Entity Type Qualifier 1 If used, will be 1 2100 NM103 Name Last or Organization Name If used, will be Recipient s Last Name 2100 NM104 Name First If used, will be Recipients First Notes Comments Codes Name Reference Loop ID 11 005010 December 2011 Name 2100 NM1 Service Provider Name 2100 NM103 Name Last of Organization Name Will be the Provider s Name as it appears on the Provider Information Sheet 2100 NM108 Identification Code Qualifier MC or FI Will be MC or FI. 2100 DTM Statement FROM or TO date 2100 DTM01 Date Time Qualifier 232, 233 Will be 232 or 233 2100 AMT Claim Supplemental Information 2100 AMT01 Amount Qualifier Code DY, F5 Will be DY for Per Day Limit and F5 for Patient Amount Paid 2100 QTY Claim Supplemental Information Quantity Notes Comments Codes Name Reference Loop ID 12 005010 December 2011 2100 QTY01 Quantity Qualifier CA Will be CA 2110 SVC Service Payment Information 2110 SVC02 Monetary Amount Will be the billed amount 2110 SVC03 Monetary Amount Will be the payment amount 2110 PLB Provider Adjustment 2110 PLB01 Reference Identification Will be the Medicaid Provider ID number, of Provider NPI when available. 2110 PLB03-2 Reference Identification Will be the HFS Process Type Code, the Recipient Identification Number and the Document Control Number (DCN) for Professional Claims, NCPDP (Pharmacy) and Long Term Care Claims. For Institutional claims, Notes Comments Codes Name Reference Loop ID 13 005010 December 2011 the Patient Control Number will be reported TI Additional Information Payer Specific Business Rules and Limitations Transmission Information: The Department s Medical Electronic Data Interchange (MEDI) system is designed to communicate electronic RA (835) information. After obtaining the proper MEDI authorization, these electronic transactions can be retrieved by the Payee. Most, but not all, of these registrations will take place using the new MEDI IEC system once that system becomes available. Certain payees, such as managed care organizations, the dental services contractor, and other State of Illinois agencies, will require a manual registration process; and they will be contacted individually prior to these systems becoming available. Once payees are authorized by a provider and registered with the Department, the Department will create an electronic RA in the 835 format regardless of the method by which the claim was submitted. Authorized payees are those parties to whom the provider has authorized the Department to make claim payments. Consistent with Department policy, only authorized payees will have access to RA notices, regardless of the format. The Department can only create the electronic RA, in the 835 format, beginning with the date upon which the authorized payee registers with the Department. The Department will make the 835 available to authorized and registered payees for a maximum period of 60 calendar days from the date of posting to the MEDI IEC web site. As with the paper RA, the Department will create a weekly electronic version of the 835 that contains only rejected claims. Please review these carefully to determine if a claim can be corrected and resubmitted to the Department for payment consideration. Note: The Department will not report suspended claims on the 835. Information regarding a suspended claim can be obtained by sending a Claim Status Request (276 transaction) to the Department. When necessary, the Department may exceed the Implementation Guide s recommended limit of 10,000 CLP (claim) segments per ST-SE envelope. Vouchers Under One Dollar The Comptroller will not pay vouchers under a dollar. In order to report these vouchers while maintaining HIPAA compliance, HFS will use the PLB segment to reduce the 4.1 4 Notes Comments Codes Name Reference Loop ID 14 005010 December 2011 payment (element BPR02) to zero. Element PLB04 will be the total for the current voucher that is under one dollar. A qualifier code of J1 will be used in element PLB03 to indicate that the payment was reduced due to a limitation that prevents payment. In order for the payees to determine the exact cause for the payment reduction, they will need to examine the claim detail for individual payment amounts. When the payee sees the voucher total is below one dollar, he she should conclude this is why no payment was received. Zero Dollar Vouchers There will be cases where the payment amount for a voucher is zero. Since the Comptroller will not create a check for less than a dollar, the 835 will still be made available to the payee. There will not be a check number. The payment date in element BPR16 will be replaced with the adjudication date of the voucher. Reporting Procedure Codes for Outpatient Institutional Claims In order to tell the provider what code was used to reimburse the claim, all procedure codes or revenue codes will be reported in the 835, regardless of whether the codes were used in adjudication. The procedure code or revenue code used for adjudication will be reported in element SVC01. Exception: Institutional Outpatient Medicare crossover claims will not be reported on a service line item basis on the 835, but will instead be reported on a claim basis. Claim Adjustment An adjustment must be reflected at either the claim level or the service level but cannot be reflected in both. There can be only one claim adjustment reason code per dollar amount. If a claim has more than one error, only one reason code will be reported on the 835. Service Provider Name This segment will be used only if the provider is different from the Payee. HFS will always complete this loop because the payee number is always different from the Billing Provider Number. In Loop 2100, NM102 (ID Code), the provider will always be coded as a non-person because HFS s provider database does not differentiate between person and non-person entities. Corrected Priority Payer Name This segment can only be used when HFS s Recipient file shows that another payer has priority for making a payment and the provider has not reported this payer in the 837. In Loop 2100, NM109, the ID Code will contain HFS s three-digit TPL code for that insurance company, followed by the group number. Per Diem Reimbursement 15 005010 December 2011 The AMT segment will be used to report the per diem amount paid. Disproportionate Share The total amount reported on the 835 will include the disproportionate share amount. 16 005010 December 2011 Replacement and Void of Prior Claim Transactions Provider initiated voids will be processed on the next available voucher. A provider initiated replacement claim (void re-bill) will be vouchered on the same date as the void s matching re-bill claim. This will mean that the void will be held in the MMIS system until the replacement claim is adjudicated (paid or rejected). When a post adjudication adjustment is created by either HFS or the provider, the original claim or service section will be voided reversed and then recreated with the adjusted amount on the 835. Note: According to the 835 Implementation Guide, the reversal does not contain any patient responsibility amount in CLP or CAS segments. Mass Adjustment A mass adjustment is used to adjust a paid claim when no detail is available on claims history, deposit a check received from a provider with no detail, and recover an amount owed to the Department due to an audit or possibly an open aged adjustment. There are several adjustment process types that are considered mass adjustments such as 09D, 32C, 15C, and 06C. Mass-to-Detail (M-T-D) Adjustment A calculated net adjustment comprised of one or more lines of detail adjustments processed by recipient and date of service. The net adjustment (mass) of the detail lines is posted as a credit or debit and paid or recovered on the remittance advice and can be identified as an "alien recipient". A report is mailed separately to provider, which provides the detail of the mass adjustment. The mass adjustment can be matched with the detail by using the document control number (DCN) on the remittance advice and detail report. 17 005010 December 2011 REMITTANCE ADVICE TRANSACTION SET AND TOTAL PAYMENT AMOUNT When the payment amount in element BPR02 is 0 the following elements will be set as follows: BPR01 H BPR04 NON N102 in loop 1000A (payer name) will be "ILLINOIS MEDICAID". N301 in loop 1000A (payer street address) will be "201 SOUTH GRAND AVENUE EAST" N401 in loop 1000A (Payer city) will be "SPRINGFIELD" N402 in loop 1000A (Payer state) will IL N403 in loop 1000A (Payer ZIP) will be 62763 When the payment amount in element BPR02 is greater than or equal to 1 the following elements will be set as follows: BPR01 I BPR04 CHK or ACH N102 in loop 1000A (payer name) will be "ILLINOIS COMPTROLLER". N301 in loop 1000A (payer street address) will be "325 W. ADAMS ST" N401 in loop 1000A (Payer city) will be SPRINGFIELD N402 in loop 1000A (Payer state) will IL N403 in loop 1000A (Payer ZIP) will be 627041871 Claim Overpayment and Recovery The Department s claims processing system will recognize that money is owed to the Department by a payee in several situations. One of these situations is when a previously paid claim is voided or is reduced as a result of a post-payment adjustment. Another situation, not related to specific claims, is when a review or a financial recovery instance results in the payee owing money to the Department. In each situation, when it is recognized that the payee owes money to the Department, the amount of the credit due is posted to the Department s accounting system. However, the credit may or may not be recouped or applied within the same 835 transaction. A PLB segment containing the overpayment recovery ( WO ) qualifier in PLB03-1, with the negative dollar amount of the credit posted will be provided within the 835 to show that the credit is due but not yet recouped. When a recovery is made to satisfy this credit (either within the same 835 or a later 835) another PLB segment will be provided containing the dollar amount of the recovery (application of credit) expressed as a positive value and containing the overpayment recovery ( WO ) qualifier in PLB03-1. These two types of PLB segments will be provided in addition to the CLP segments (for detail claim voids or adjustments) and the PLB segments (for provider level adjustments) that caused the credit to be owed to the Department initially. These PLB segments serve to allow the 835 to balance to the amount paid. They also allow the payee to be notified of each instance of a credit amount due the Department and each application or 4.2 18 005010 December 2011 recovery of a credit, even when the application does not fully recover the entire amount owed to the Department. For Professional Claims, NCPDP (Pharmacy Claims) Long Term Care Claims, three items of information will be included in the PLB03-2 element to enable the PLB segment to be associated with the original claim or provider level adjustment: 1. HFS Process Type code 2. Recipient Identification Number 3. Document Control Number (DCN) of the original claim or of the provider level adjustment. For Institutional Claims, the patient control number will be reported in the PLB03-2 element to enable the PLB segment to be associated with the original claim or provider level adjustment. The Department will not use the forwarding balance method, as allowed by the 835 - Implementation Guide, to denote the amount owed by the Payee. Example of a Voided Claim When a claim is voided, it will be reported in the 835 by using a CLP segment with a status code of 22. This CLP reversal will reduce the total payment amount represented in element BPR02. Since the amount owed to the Department as a result of voiding the previously paid claim may not be recovered within this 835, it is necessary to offset this amount to cause the payment in BPR02 to match the amount actually paid by the check associated with this 835. This is done by issuing a PLB segment with an adjustment qualifier of WO and a negative amount equaling the net effect of the reversal CLP segment. RA on which the claim is voided: CLP 1234 22 -100 -100 orig DCN 1 REF F8 DCN of previous adjustment PLB prov num 20031231 WO:PRCS type recip ID orig DCN 1 -100 A later RA on which the money owed is recovered: PLB prov num 20031231 WO:PRCS type recip ID orig DCN 1 100 Example of Voided Claim with Returned Check When a claim is voided by the Payee remitting to the Department the amount of the net payment for the claim, the RA will reflect a PLB segment which contains a WO adjustment reason code for the amount as well as an offsetting adjustment 72 reason code and amount. No CLP segment will be returned. PLB03-2 and PLB05-2 will vary depending on the type of claim. Institutional claims will contain the patient account number, professional claims will contain adjustment process type, recipient number, and the original DCN, and Pharmacy claims will contain the prescription number. RA on which the voided claim with returned check is shown: PLB prov num 19870430 WO:ClaimIdentifier 100 72:ClaimIdentifier -100 19 005010 December 2011 Example of a Re-billed Claim (Bill Frequency 7) RA on which the original claim is reversed and replaced: CLP 1234 22 -100 -100 orig DCN 1 REF F8 DCN of previous adjustment CLP 1234 1 100 90 new DCN 2 REF F8 orig DCN 1 PLB prov num 20031231 WO: PRCS type recip ID orig DCN 1 -100 In this case, claim DCN 1 originally paid at 100 is being reversed. A new claim has been adjudicated at the new payment amount of 90. The PLB prevents the total payment of the voucher from being reduced and informs the payee that the money owed is not being recovered at this point. RA on which the money owed is recovered: PLB prov num 20031231 WO: PRCS type recip ID orig DCN 1 100 The REF segment in loop 2100 Use of this segment is only for Long Term Care (LTC) claims and adjustments. The REF segment may be used in reversal CLP segments. This segment will carry the DCN of the previous adjustment if this claim has been adjusted prior to the current adjustment. If the current adjustment is the first adjustment then the REF segment will not be used. Element REF01 will have the qualifier F8 and element REF02 will have the DCN. This will allow the department to create a history chain from the most recent adjustment to the original claim. This will include DCNs of the detail portions of MASS-to-DETAIL adjustments. The MASS-to-DETAIL adjustments are not sent in the 835 using the CLP reversal and correction process. MASS-to-DETAIL adjustments are reported in the PLB using the DCN of the mass portion of the MASS-to-DETAIL. In order to maintain the history chain in the reversal and correction process, the REF segment in the reversal CLP may refer to the DCN of a detail portion of a MASS-to-DETAIL adjustment. If the REF segment refers to a MASS-to-DETAIL DCN then the provider will not find that DCN in a CLP segment of a previous claim. There will always be a REF segment in the correction CLP of all adjustments that create correction CLP segments. This REF segment will refer back to element CLP07 of the associated reversal segment, not the REF segment of the reversal CLP segment. Element REF01 will have the qualifier F8 and element REF02 will have the DCN. PATIENT NAME (NM1) SEGMENT The patient name is a required segment in the 835; however the patient name may not be available when processing a claim that was submitted prior to the implementation of HIPAA. Even prior to HIPAA, HFS would reject a claim submitted without the recipient 20 005010 December 2011 name or number; however, it is possible that HFS may have to reprocess pre-HIPAA claim data through the adjudication system. When the 835 system encounters a rejected claim that has no recipient data then HFS will return not received in elements NM103 (last name) and NM104 (first name). If the recipient number is missing, HFS will return 000000000 in element NM109 (identification code). Questions, comments, or suggestions regarding this information should be directed to the HFS Webmaster. 21 005010 December 2011 TI Change Summary Revision Date: Revision Description: Revision Date: Revision Description: Revision Date: Revision Description: Revision Date: Revision Description: Revision Date: Revision Description: Revision Date: Revision Description: Revision Date: Revision Description: 5 22 005010 December 2011 23 005010 December 2011 | /kaggle/input/edi-db-835-837/835.pdf | 9da6e72b7d59f795d3710e934e0e4629 | 9da6e72b7d59f795d3710e934e0e4629_0 |
Companion Guide X12 837P Revision Date: January 2011 3-1 Version 3.0 X12 837P Companion Guide January 2011 Companion Guide X12 837P Revision Date: January 2011 3-2 Version 3.0 Table of Contents Section 1: Revision History....................................................................................... 4 Section 2: Professional Claims and Encounters...................................................... 5 Introduction............................................................................................................. 5 Segment Usage 837 Professional......................................................................... 6 Segment and Data Element Description................................................................ 13 Header............................................................................................................... 14 ST - Transaction Set Header......................................................................... 14 BHT - Beginning of Hierarchical Transaction.............................................. 14 NM1 - Submitter Name................................................................................ 14 PER - Submitter EDI Contact Information................................................... 14 NM1 - Receiver Name.................................................................................. 14 Billing Provider Detail...................................................................................... 15 HL - Billing Pay-To Provider Hierarchical Level........................................ 15 NM1 - Billing Provider Name...................................................................... 15 N3 - Billing Provider Address...................................................................... 15 N4 - Billing Provider City State ZIP Code................................................... 15 REF - Billing Provider Tax Identification.................................................... 15 REF - Billing Provider UPIN License Information...................................... 16 PER - Billing Provider Contact Information................................................ 16 NM1 - Pay-To Provider Name...................................................................... 16 N3 - Pay-To Provider Address...................................................................... 16 N4 - Pay-To Provider City State ZIP Code.................................................. 16 Subscriber Detail............................................................................................... 17 HL - Subscriber Hierarchical Level.............................................................. 17 SBR - Subscriber Information...................................................................... 17 NM1 - Subscriber Name............................................................................... 17 N3 - Subscriber Address............................................................................... 18 N4 - Subscriber City State ZIP Code............................................................ 18 DMG - Subscriber Demographic Information.............................................. 18 REF - Subscriber Secondary Information..................................................... 18 NM1 - Payer Name....................................................................................... 18 Claim Information............................................................................................. 19 CLM - Claim Information............................................................................ 19 DTP - Date Onset of Current Illness or Symptom..................................... 19 DTP - Date Initial Treatment..................................................................... 19 DTP - Date Accident................................................................................. 19 DTP - Date - Admission............................................................................... 19 DTP - Date Discharge Date....................................................................... 19 PWK - Claim Supplemental Information..................................................... 20 AMT - Patient Paid Amount......................................................................... 20 REF- Referral Number................................................................................. 20 REF- Prior Authorization............................................................................. 20 REF Payer Claim Control Number............................................................ 20 REF - Medical Record Number.................................................................... 20 NTE - Claim Note......................................................................................... 21 HI - Health Care Diagnosis Code................................................................. 21 HI - Anesthesia Related Procedure............................................................... 21 HI - Condition Information........................................................................... 21 NM1 - Referring Provider Name.................................................................. 21 Companion Guide X12 837P Revision Date: January 2011 3-3 Version 3.0 REF - Referring Provider Secondary Identification..................................... 21 NM1 - Rendering Provider Name................................................................. 22 PRV - Rendering Provider Specialty Information........................................ 22 REF - Rendering Provider Secondary Information....................................... 22 NM1 Service Facility Location Name....................................................... 22 N3 Service Facility Location Address....................................................... 23 N4 Service Facility Location City, State, Zip Code.................................. 23 REF Service Facility Location Secondary Identification........................... 23 PER Service Facility Contact Information................................................ 23 SBR - Other Subscriber Information............................................................ 23 CAS - Claim Level Adjustment.................................................................... 23 AMT Coordination of Benefits (COB) Payer Paid Amount...................... 24 AMT Remaining Patient Liability............................................................. 24 OI Other Insurance Coverage Information................................................ 24 MOA Outpatient Adjudication Information.............................................. 24 NM1 Other Subscriber Name.................................................................... 24 N3 Other Subscriber Address.................................................................... 24 N4 Other Subscriber City, State, Zip Code................................................ 25 REF Other Subscriber Secondary Identification........................................ 25 NM1 Other Payer Name............................................................................ 25 N3 Other Payer Address............................................................................ 25 N4 Other Payer City, State, Zip Code........................................................ 25 DTP Claim Check or Remittance Date...................................................... 25 REF Other Payer Prior Authorization Number.......................................... 26 LX - Service Line......................................................................................... 26 SV1 - Professional Service........................................................................... 26 DTP - Date Service Date........................................................................... 26 REF - Prior Authorization or Referral Number............................................ 26 REF - Line Item Control Number................................................................. 26 CAS - Service Line Adjustment................................................................... 27 Transaction Set Trailer...................................................................................... 27 SE - Transaction Set Trailer......................................................................... 27 Companion Guide X12 837P Revision Date: January 2011 3-4 Version 3.0 Section 1: Revision History Document Version Number Revision Date Revision Page Number(s) Reason for Revisions Revisions Completed By Version 1.0 ISDH HIPAA Version 2.0 ISDH HIPAA Version 3.0 January 2011 All 5010 Implementation ISDH HIPAA Companion Guide X12 837P Revision Date: January 2011 3-5 Version 3.0 Section 2: Professional Claims and Encounters Introduction The ASC X12N 837 (005010X222A1) transaction is the HIPAA mandated instrument by which professional claim or encounter data must be submitted. Any claim that would be submitted on a HCFA CMS-1500 claim form must be submitted using this transaction if the data is submitted electronically. This document is intended only as a companion guide to and is not intended to contradict or replace any information in the EDI Implementation Guides (IG). It is highly recommended that implementers have the following resources available during the development process: This document, Companion Guide 837 Professional Claims and Encounters Transactions ASC X12N 837 0005010X222 Implementation Guide ASC X12N 837 0005010X222A1 Implementation Guide Addenda A 999 Implementation Acknowledgement file will be sent to acknowledge all 837 transaction sets that are sent to ISDH. An 835 Payment Advice will be sent for all HIPAA Compliant 837 claims. See the companion guides for these transactions on our web site for more information: http: www.cshcs.in.gov and then going to the EDI Solutions section. Additionally, there are several processing assumptions, limitations, and guidelines a developer must be aware of when implementing the 837P transaction. The following list identifies these processing stipulations: ISDH will be validating at the ST-SE level. We recommend that you take this into consideration when deciding how many claims to submit within a single ST-SE as a single error will cause the entire transaction set (ST-SE) to be rejected. Companion Guide X12 837P Revision Date: January 2011 3-6 Version 3.0 Segment Usage 837 Professional The following matrix lists all segments within the 5010 version of the 837P IG. The ISDH Usage column indicates which segments are required, situational or not used by ISDH. A required segment element must appear on all transactions. Failure to include a required segment results in a compliance error. A situational segment is not required for every type transaction; however, a situational segment may be required under certain circumstances. Any data in a segment that is identified in the Usage column with an X is ignored by ISDH. Any segment identified in the Usage column as required or situational is explained in detail in the Segment and Data Element Description section of the document. Table 3.1 Segment Usage 837 Professional Segment ID Loop ID Segment Name ISDH Usage R Required S Situational X Not Used ST N A Transaction Set Header R BHT N A Beginning of Hierarchical Transaction R NM1 1000A Submitter Name R PER 1000A Submitter EDI Contact Information R NM1 1000B Receiver Name R HL 2000A Billing Pay-To Hierarchical Level R PRV 2000A Billing Pay-To Specialty Information X CUR 2000A Foreign Currency Information X NM1 2010AA Billing Provider Name R N3 2010AA Billing Provider Address R N4 2010AA Billing Provider City State ZIP Code R REF 2010AA Billing Provider Tax Identification R REF 2010AA Billing Provider UPIN License Information X PER 2010AA Billing Provider Contact Information S NM1 2010AB Pay-To Provider Name S N3 2010AB Pay-To Provider Address R N4 2010AB Pay-To Provider City State ZIP Code R NM1 2010AC Pay To Plan Name X N3 2010AC Pay To Plan Address X N4 2010AC Pay To Plan City State ZIP Code X HL 2000B Subscriber Hierarchical Level R Companion Guide X12 837P Revision Date: January 2011 3-7 Version 3.0 Table 3.1 Segment Usage 837 Professional Segment ID Loop ID Segment Name ISDH Usage R Required S Situational X Not Used SBR 2000B Subscriber Information R PAT 2000B Patient Information X NM1 2010BA Subscriber Name R N3 2010BA Subscriber Address S N4 2010BA Subscriber City State ZIP Code S DMG 2010BA Subscriber Demographic Information S REF 2010BA Subscriber Secondary Information S REF 2010BA Property and Casualty Claim Number X PER 2010BA Property and Casualty Subscriber Contact Information X NM1 2010BB Payer Name R N3 2010BB Payer Address X N4 2010BB Payer City State ZIP Code X REF 2010BB Payer Secondary Information X REF 2010BB Billing Provider Secondary Identification X HL 2000C Patient Hierarchical Level X PAT 2000C Patient Information X NM1 2010CA Patient Name X N3 2010CA Patient Address X N4 2010CA Patient City State ZIP Code X DMG 2010CA Patient Demographic Information X REF 2010CA Property and Casualty Claim Number X PER 2010CA Property and Casualty Patient Contact Information X CLM 2300 Claim Information R DTP 2300 Date Onset of Current Illness or Symptom S DTP 2300 Date Initial Treatment Date S DTP 2300 Date Last Seen Date X DTP 2300 Date Acute Manifestation X DTP 2300 Date Accident S DTP 2300 Date Last Menstrual Period X DTP 2300 Date Last X-Ray X DTP 2300 Date Hearing and Vision Prescription Date X DTP 2300 Date Disability Dates X Companion Guide X12 837P Revision Date: January 2011 3-8 Version 3.0 Table 3.1 Segment Usage 837 Professional Segment ID Loop ID Segment Name ISDH Usage R Required S Situational X Not Used DTP 2300 Date Date Last Worked X DTP 2300 Date Authorized Return to Work X DTP 2300 Date Admission S DTP 2300 Date Date Discharge S DTP 2300 Date Assumed and Relinquished Care Dates X DTP 2300 Date Property and Casualty Date of First Contact X DTP 2300 Date Repricer Received Date X PWK 2300 Claim Supplemental Information S CN1 2300 Contract Information X AMT 2300 Patient Paid Amount S REF 2300 Service Authorization Exception Code X REF 2300 Mandatory Medicare (Section 4081) Crossover Indicator X REF 2300 Mammography Certification Number X REF 2300 Referral Number S REF 2300 Prior Authorization S REF 2300 Payer Claim Control Number X REF 2300 Clinical Laboratory Improvement Amendment (CLIA) Number X REF 2300 Re-priced Claim Number X REF 2300 Adjusted Re-priced Claim Number X REF 2300 Investigational Device Exemption Number X REF 2300 Claim Identifier for Transmission Intermediaries X REF 2300 Medical Record Number S REF 2300 Demonstration Project Identifier X REF 2300 Care Plan Oversight X K3 2300 File Information X NTE 2300 Claim Note S CR1 2300 Ambulance Transport Information X CR2 2300 Spine Manipulation Service Information X CRC 2300 Ambulance Certification X Companion Guide X12 837P Revision Date: January 2011 3-9 Version 3.0 Table 3.1 Segment Usage 837 Professional Segment ID Loop ID Segment Name ISDH Usage R Required S Situational X Not Used CRC 2300 Patient Condition Information: Vision X CRC 2300 Homebound Indicator X CRC 2300 EPSDT Referral X HI 2300 Health Care Diagnosis Code R HI 2300 Anesthesia Related Procedure S HI 2300 Condition Information S HCP 2300 Claim Pricing Re-pricing Information X NM1 2310A Referring Provider Name S REF 2310A Referring Provider Secondary Information S NM1 2310B Rendering Provider Name S PRV 2310B Rendering Provider Specialty Information S REF 2310B Rendering Provider Secondary Identification S NM1 2310C Service Facility Location Name S N3 2310C Service Facility Location Address S N4 2310C Service Facility Location City State ZIP Code S REF 2310C Service Facility Location Secondary Identification X PER 2310C Service Facility Contact Information X NM1 2310D Supervising Provider Name X REF 2310D Supervising Provider Secondary Information X NM1 2310E Ambulance Pick-Up Location X N3 2310E Ambulance Pick-Up Location Address X N4 2310E Ambulance Pick-Up Location City, State, Zip Code X NM1 2310F Ambulance Drop-Off Location X N3 2310F Ambulance Drop-Off Location Address X N4 2310F Ambulance Drop-Off Location City, State, Zip Code X SBR 2320 Other Subscriber Information S CAS 2320 Claim Level Adjustment S AMT 2320 Coordination of Benefits (COB) Payer Paid Amount S AMT 2320 Remaining Patient Liability S OI 2320 Other Insurance Coverage Information S Companion Guide X12 837P Revision Date: January 2011 3-10 Version 3.0 Table 3.1 Segment Usage 837 Professional Segment ID Loop ID Segment Name ISDH Usage R Required S Situational X Not Used MOA 2320 Medicare Outpatient Adjudication Information X NM1 2330A Other Subscriber Name R N3 2330A Other Subscriber Address S N4 2330A Other Subscriber City State ZIP Code R REF 2330A Other Subscriber Secondary Information S NM1 2330B Other Payer Name S N3 2330A Other Payer Address S N4 2330A Other Payer City State ZIP Code R DTP 2330B Claim Check or Remittance Date X REF 2330B Other Payer Secondary Identifier X REF 2330B Other Payer Prior Authorization Number S REF 2330B Other Payer Referral Number S REF 2330B Other Payer Claim Adjustment Indicator X REF 2330B Other Payer Claim Control Number X NM1 2330C Other Payer Referring Provider X REF 2330C Other Payer Referring Provider Identification X NM1 2330D Other Payer Rendering Provider X REF 2330D Other Payer Rendering Provider Secondary Identification X NM1 2330E Other Payer Service Facility Location X REF 2330E Other Payer Service Facility Location Identification X NM1 2330F Other Payer Supervising Provider X REF 2330F Other Payer Supervising Provider Identification X NM1 2330G Other Payer Billing Provider X REF 2330G Other Payer Billing Provider Secondary Identification X LX 2400 Service Line Number R SV1 2400 Professional Service R SV5 2400 Durable Medical Equipment Service X PWK 2400 Line Supplemental Information X PWK 2400 Durable Medical Equipment Certificate of Medical Necessity Indicator X Companion Guide X12 837P Revision Date: January 2011 3-11 Version 3.0 Table 3.1 Segment Usage 837 Professional Segment ID Loop ID Segment Name ISDH Usage R Required S Situational X Not Used CR1 2400 Ambulance Transport Information X CR3 2400 Durable Medical Equipment Certification X CRC 2400 Ambulance Certification X CRC 2400 Hospice Employee Indicator X CRC 2400 Condition Indicator Durable Medical Equipment X DTP 2400 Date Service Date R DTP 2400 Date Prescription Date X DTP 2400 Date Certification Revision Date X DTP 2400 Date Begin Therapy Date X DTP 2400 Date Last Certification Date X DTP 2400 Date Date Last Seen X DTP 2400 Date Test Date X DTP 2400 Date Shipped X DTP 2400 Date Last X-ray X DTP 2400 Date Initial Treatment X QTY 2400 Ambulance Patient Count X QTY 2400 Obstetric Anesthesia Additional Units X MEA 2400 Test Result X CN1 2400 Contract Information X REF 2400 Re-priced Line Item Reference Number X REF 2400 Adjusted Re-priced Line Item Reference Number X REF 2400 Prior Authorization S REF 2400 Line Item Control Number S REF 2400 Mammography Certification Number X REF 2400 Clinical Laboratory Improvement Amendment (CLIA) Information X REF 2400 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification X REF 2400 Immunization Batch Number X REF 2400 Referral Number X AMT 2400 Sales Tax Amount X AMT 2400 Postage Claimed Amount X Companion Guide X12 837P Revision Date: January 2011 3-12 Version 3.0 Table 3.1 Segment Usage 837 Professional Segment ID Loop ID Segment Name ISDH Usage R Required S Situational X Not Used K3 2400 File Information X NTE 2400 Line Note X NTE 2400 Third Party Organization Notes X PS1 2400 Purchased Service Information X HCP 2400 Line Pricing Re-pricing Information X LIN 2410 Drug Identification X CTP 2410 Drug Pricing X REF 2410 Prescription or Compound Drug Association Number X NM1 2420A Rendering Provider Name X PRV 2420A Rendering Provider Specialty Information X REF 2420A Rendering Provider Secondary Identification X NM1 2420B Purchased Service Provider Name X REF 2420B Purchased Service Provider Secondary Identification X NM1 2420C Service Facility Location X N3 2420C Service Facility Location Address X N4 2420C Service Facility Location City State ZIP Code X REF 2420C Service Facility Location Secondary Identification X NM1 2420D Supervising Provider Name X REF 2420D Supervising Provider Secondary Identification X NM1 2420E Ordering Provider Name X N3 2420E Ordering Provider Address X N4 2420E Ordering Provider City State ZIP Code X REF 2420E Ordering Provider Secondary Identification X PER 2420E Ordering Provider Contact Information X NM1 2420F Referring Provider Name X REF 2420F Referring Provider Secondary Identification X NM1 2420G Ambulance Pick-Up Location X N3 2420G Ambulance Pick-Up Location Address X N4 2420G Ambulance Pick-Up Location City, State, Zip Code X NM1 2420H Ambulance Drop-Off Location X Companion Guide X12 837P Revision Date: January 2011 3-13 Version 3.0 Table 3.1 Segment Usage 837 Professional Segment ID Loop ID Segment Name ISDH Usage R Required S Situational X Not Used N3 2420H Ambulance Drop-Off Location Address X N4 2420H Ambulance Drop-Off Location City, State, Zip Code X SVD 2430 Line Adjudication Information X CAS 2430 Line Adjustment S DTP 2430 Line Check or Remittance Date X AMT 2430 Remaining Patient Liability X LQ 2440 Form Identification Code X FRM 2440 Supporting Documentation X SE N A Transaction Set Trailer R Segment and Data Element Description This section contains a tabular representation of any segment required or situational for the ISDH HIPAA implementation of the 837P. Each segment table contains rows and columns describing different segment elements. Segment Name The industry assigned segment name as identified in the IG. Segment ID The industry assigned segment ID as identified in the IG. Loop ID The loop within which the segment should appear. Usage Identifies the segment as required or situational. Segment Notes A brief description of the purpose or use of the segment. Example An example of complete segment. Element ID The industry assigned data element ID as identified in the IG. Usage Identifies the data element as R-required, S-situational, or N A-not used. Guide Description Valid Values Industry name associated with the data element. If no industry name exists, this is the IG data element name. This column also lists in BOLD the values and or code set to be used. Comments Description of the contents of the data elements including field lengths. Companion Guide X12 837P Revision Date: January 2011 3-14 Version 3.0 Header Segment Name ST - Transaction Set Header Segment ID ST Loop ID N A Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name BHT - Beginning of Hierarchical Transaction Segment ID BHT Loop ID N A Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name NM1 - Submitter Name Segment ID NM1 Loop ID 1000A Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name PER - Submitter EDI Contact Information Segment ID PER Loop ID 1000A Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name NM1 - Receiver Name Segment ID NM1 Loop ID 1000B Usage Required Segment Notes Follow the HIPAA and IG rules. Companion Guide X12 837P Revision Date: January 2011 3-15 Version 3.0 Billing Provider Detail Segment Name HL - Billing Pay-To Provider Hierarchical Level Segment ID HL Loop ID 2000A Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name NM1 - Billing Provider Name Segment ID NM1 Loop ID 2010AA Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name N3 - Billing Provider Address Segment ID N3 Loop ID 2010AA Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name N4 - Billing Provider City State ZIP Code Segment ID N4 Loop ID 2010AA Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name REF - Billing Provider Tax Identification Segment ID REF Loop ID 2010AA Usage Required Segment Notes Follow the HIPAA and IG rules. Companion Guide X12 837P Revision Date: January 2011 3-16 Version 3.0 Segment Name REF - Billing Provider UPIN License Information Segment ID REF Loop ID 2010AA Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name PER - Billing Provider Contact Information Segment ID PER Loop ID 2010AA Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name NM1 - Pay-To Provider Name Segment ID NM1 Loop ID 2010AB Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name N3 - Pay-To Provider Address Segment ID N3 Loop ID 2010AB Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name N4 - Pay-To Provider City State ZIP Code Segment ID N4 Loop ID 2010AB Usage Required Segment Notes Follow the HIPAA and IG rules. Companion Guide X12 837P Revision Date: January 2011 3-17 Version 3.0 Subscriber Detail Segment Name HL - Subscriber Hierarchical Level Segment ID HL Loop ID 2000B Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name SBR - Subscriber Information Segment ID SBR Loop ID 2000B Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name NM1 - Subscriber Name Segment ID NM1 Loop ID 2010BA Usage Required Segment Notes See ISDH specific rules below. Example NM1 IL 1 DOE JOHN T MI 123456 Element ID Usage Guide Description Valid Values Comments NM101 R Entity Identifier Code IL Insured or Subscriber NM102 R Entity Type Qualifier 1 Person NM103 R Subscriber s Last Name NM104 S Subscriber s First Name NM105 S Subscriber s Middle Initial NM106 N A Name Prefix Not used per IG NM107 S Subscriber Name Suffix NM108 R Identification Code Qualifier MI Member Identification Number Companion Guide X12 837P Revision Date: January 2011 3-18 Version 3.0 Element ID Usage Guide Description Valid Values Comments NM109 R Subscriber Primary Identifier This field is required by ISDH. NM110 N A Entity Relationship Code Not used per IG NM111 N A Entity Identifier Code Not used per IG NM112 N A Name Last or Organization Name Not used per IG Segment Name N3 - Subscriber Address Segment ID N3 Loop ID 2010BA Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name N4 - Subscriber City State ZIP Code Segment ID N4 Loop ID 2010BA Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name DMG - Subscriber Demographic Information Segment ID DMG Loop ID 2010BA Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name REF - Subscriber Secondary Information Segment ID REF Loop ID 2010BA Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name NM1 - Payer Name Segment ID NM1 Loop ID 2010BB Payer Name Usage Required Segment Notes Follow the HIPAA and IG rules. Companion Guide X12 837P Revision Date: January 2011 3-19 Version 3.0 Claim Information Segment Name CLM - Claim Information Segment ID CLM Loop ID 2300 Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name DTP - Date Onset of Current Illness or Symptom Segment ID DTP Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name DTP - Date Initial Treatment Segment ID DTP Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name DTP - Date Accident Segment ID DTP Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name DTP - Date - Admission Segment ID DTP Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name DTP - Date Discharge Date Segment ID DTP Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Companion Guide X12 837P Revision Date: January 2011 3-20 Version 3.0 Segment Name PWK - Claim Supplemental Information Segment ID PWK Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name AMT - Patient Paid Amount Segment ID AMT Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name REF- Referral Number Segment ID REF Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name REF- Prior Authorization Segment ID REF Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name REF Payer Claim Control Number Segment ID REF Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name REF - Medical Record Number Segment ID REF Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Companion Guide X12 837P Revision Date: January 2011 3-21 Version 3.0 Segment Name NTE - Claim Note Segment ID NTE Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name HI - Health Care Diagnosis Code Segment ID HI Loop ID 2300 Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name HI - Anesthesia Related Procedure Segment ID HI Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name HI - Condition Information Segment ID HI Loop ID 2300 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name NM1 - Referring Provider Name Segment ID NM1 Loop ID 2310A Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name REF - Referring Provider Secondary Identification Segment ID REF Loop ID 2310A Usage Situational Segment Notes Follow the HIPAA and IG rules. Companion Guide X12 837P Revision Date: January 2011 3-22 Version 3.0 Segment Name NM1 - Rendering Provider Name Segment ID NM1 Loop ID 2310B Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name PRV - Rendering Provider Specialty Information Segment ID PRV Loop ID 2310B Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name REF - Rendering Provider Secondary Information Segment ID REF Loop ID 2310B Usage Situational Segment Notes If this loop is used, one instance must use REF01 G2 per ISDH rules. Example REF G2 123456 Element ID Usage Guide Description Valid Values Comments REF01 R Reference Identification Qualifier G2 Provider Commercial Number Use G2 for one instance of this loop. Other instances of this loop can be sent with other codes. See IG for list of valid codes. Per HIPAA compliance, this loop can repeat up to 20 times. It is ISDH s rule that one of these instances must use Reference Id Qualifier G2. REF02 R Billing Provider Additional Identifier When REF01 G2 then REF02 ISDH assigned provider id. REF03 N A Description Not used REF04 N A Reference Identifier Not used Segment Name NM1 Service Facility Location Name Segment ID NM1 Loop ID 2310C Usage Situational Segment Notes Follow the HIPAA and IG rules. Companion Guide X12 837P Revision Date: January 2011 3-23 Version 3.0 Segment Name N3 Service Facility Location Address Segment ID N3 Loop ID 2310C Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name N4 Service Facility Location City, State, Zip Code Segment ID N4 Loop ID 2310C Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name REF Service Facility Location Secondary Identification Segment ID REF Loop ID 2310C Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name PER Service Facility Contact Information Segment ID RPER Loop ID 2310C Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name SBR - Other Subscriber Information Segment ID SBR Loop ID 2320 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name CAS - Claim Level Adjustment Segment ID CAS Loop ID 2320 Usage Situational Segment Notes Follow the HIPAA and IG rules. Companion Guide X12 837P Revision Date: January 2011 3-24 Version 3.0 Segment Name AMT Coordination of Benefits (COB) Payer Paid Amount Segment ID AMT Loop ID 2320 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name AMT Remaining Patient Liability Segment ID AMT Loop ID 2320 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name OI Other Insurance Coverage Information Segment ID OI Loop ID 2320 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name MOA Outpatient Adjudication Information Segment ID MOA Loop ID 2320 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name NM1 Other Subscriber Name Segment ID NM1 Loop ID 2320A Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name N3 Other Subscriber Address Segment ID N3 Loop ID 2320A Usage Situational Segment Notes Follow the HIPAA and IG rules. Companion Guide X12 837P Revision Date: January 2011 3-25 Version 3.0 Segment Name N4 Other Subscriber City, State, Zip Code Segment ID N4 Loop ID 2320A Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name REF Other Subscriber Secondary Identification Segment ID REF Loop ID 2320A Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name NM1 Other Payer Name Segment ID NM1 Loop ID 2330B Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name N3 Other Payer Address Segment ID N3 Loop ID 2330B Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name N4 Other Payer City, State, Zip Code Segment ID N4 Loop ID 2330B Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name DTP Claim Check or Remittance Date Segment ID DTP Loop ID 2330B Usage Situational Segment Notes Follow the HIPAA and IG rules. Companion Guide X12 837P Revision Date: January 2011 3-26 Version 3.0 Segment Name REF Other Payer Prior Authorization Number Segment ID REF Loop ID 2330B Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name LX - Service Line Segment ID LX Loop ID 2400 Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name SV1 - Professional Service Segment ID SV1 Loop ID 2400 Usage Required Segment Notes Follow the HIPAA and IG rules Segment Name DTP - Date Service Date Segment ID DTP Loop ID 2400 Usage Required Segment Notes Follow the HIPAA and IG rules. Segment Name REF - Prior Authorization or Referral Number Segment ID REF Loop ID 2400 Usage Situational Segment Notes Follow the HIPAA and IG rules. Segment Name REF - Line Item Control Number Segment ID REF Loop ID 2400 Usage Situational Segment Notes Follow the HIPAA and IG rules. Companion Guide X12 837P Revision Date: January 2011 3-27 Version 3.0 Segment Name CAS - Service Line Adjustment Segment ID CAS Loop ID 2430 Usage Situational Segment Notes Follow the HIPAA and IG rules. Transaction Set Trailer Segment Name SE - Transaction Set Trailer Segment ID SE Loop ID N A Usage Required Segment Notes Follow the HIPAA and A1 IG rules. | /kaggle/input/edi-db-835-837/837P_Companion_Guide_5010.pdf | 6b1d3005c612135e687a29d6c2e69812 | 6b1d3005c612135e687a29d6c2e69812_0 |
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 837 Health Care Claim: Professional (X222A2) 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 1 665 View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view hipaa health-care-claim-professional- x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE POWERED BY Build EDI implementation guides at stedi.com 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 Subscriber Secondary Identification Max use 1 Optional REF 0350 Property and Casualty Claim Number 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 Payer Secondary Identification Max use 3 Optional REF 0350 Billing Provider Secondary Identification Max use 2 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - Last Menstrual Period Max use 1 Optional DTP 1350 Date - Onset of Current Illness or Symptom Max use 1 Optional DTP 1350 Date - Initial Treatment Date 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 - 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 Clinical Laboratory Improvement Amendment (CLIA) Number 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 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries 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 Prior Authorization Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 5 665 REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Medical Record 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 Patient Condition Information: Vision Max use 3 Optional CRC 2200 Homebound Indicator Max use 1 Optional CRC 2200 EPSDT Referral Max use 1 Optional HI 2310 Health Care Diagnosis Code Max use 1 Required HI 2310 Anesthesia Related Procedure Max use 1 Optional HI 2310 Condition Information Max use 2 Optional 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 Secondary Identifier Max use 2 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 Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 Line Supplemental Information Max use 10 Optional PWK 4200 Durable Medical Equipment Certificate of Medical Necessity Indicator Max use 1 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 Hospice Employee Indicator Max use 1 Optional CRC 4500 Condition Indicator Durable Medical Equipment Max use 1 Optional DTP 4550 Date - Service Date Max use 1 Required DTP 4550 Date - Prescription Date Max use 1 Optional DTP 4550 DATE - Certification Revision Recertification Date Max use 1 Optional DTP 4550 Date - Begin Therapy 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 - 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 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 9 665 REF 4700 Mammography Certification Number Max use 1 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 REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Prior Authorization Max use 5 Optional AMT 4750 Sales Tax Amount Max use 1 Optional AMT 4750 Postage Claimed 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - Last Menstrual Period Max use 1 Optional DTP 1350 Date - Onset of Current Illness or Symptom Max use 1 Optional DTP 1350 Date - Initial Treatment Date Max use 1 Optional 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 12 665 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 - 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 Clinical Laboratory Improvement Amendment (CLIA) Number 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 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries 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 Prior Authorization Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 13 665 CRC 2200 Patient Condition Information: Vision Max use 3 Optional CRC 2200 Homebound Indicator Max use 1 Optional CRC 2200 EPSDT Referral Max use 1 Optional HI 2310 Health Care Diagnosis Code Max use 1 Required HI 2310 Anesthesia Related Procedure Max use 1 Optional HI 2310 Condition Information Max use 2 Optional 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 Secondary Identifier Max use 2 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 Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 Line Supplemental Information Max use 10 Optional PWK 4200 Durable Medical Equipment Certificate of Medical Necessity Indicator Max use 1 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 Hospice Employee Indicator Max use 1 Optional 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 16 665 CRC 4500 Condition Indicator Durable Medical Equipment Max use 1 Optional DTP 4550 Date - Service Date Max use 1 Required DTP 4550 Date - Prescription Date Max use 1 Optional DTP 4550 DATE - Certification Revision Recertification Date Max use 1 Optional DTP 4550 Date - Begin Therapy 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 - 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 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 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 REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Prior Authorization Max use 5 Optional AMT 4750 Sales Tax Amount Max use 1 Optional AMT 4750 Postage Claimed Amount Max use 1 Optional K3 4800 File Information Max use 10 Optional 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 250130 2355 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 22 665 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HC XXXXXXX XXX 20250130 0423 00000 XX 005010X2 22A2 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 00 X 20250131 0325 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 1 XXXX X XXX 46 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX TE XX FX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 32 665 Heading end 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_0 |
country or area code when applicable 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 32 665 Heading end 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 1 XX XXXXXX X 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX 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. 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 40 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX FX XXX EM XXXXX TE XXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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. 1 Person 2 Non-Person Entity 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XX XXXXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 48 665 2010AB Pay-to Address Name Loop end 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX PI 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX XX XXXXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 NF 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 56 665 0 No Subordinate HL Segment in This Hierarchical Structure. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 G 18 XXXX XX 43 17 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 59 665 ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 61 665 For this implementation, the listed value takes precedence over the semantic note. Y Yes 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 2 XXXXXX XX XXXXXX XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX XX XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 66 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 68 665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 69 665 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 XXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 PER-05 365 Communication Number Qualifier Identifier (ID) Optional 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXXX XX XXXXXXXX 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) | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_1 |
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXXX XX XXXXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 76 665 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 77 665 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 2U XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 78 665 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 G2 XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X 000000000 X B X Y A N I P EM XXX XX XX 0 3 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. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 81 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 82 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 83 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 85 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 87 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 89 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 93 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 361 RD8 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 - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 97 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 99 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 100 665 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 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 101 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 102 665 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 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 - Initial Treatment Date 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 103 665 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 104 665 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 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 - Onset of Current Illness or Symptom 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 105 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 106 665 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 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 107 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 108 665 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 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 109 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 110 665 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 111 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 113 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_2 |
or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 113 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 115 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 OC FX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 06 00000000 000 XXX 00 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 00000000000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 122 665 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 XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 123 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 124 665 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 XXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 125 665 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 XXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 126 665 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 XXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 127 665 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 X Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 128 665 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 Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 129 665 The value carried in this element is limited to a maximum of 20 positions. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 132 665 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 XXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 133 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 134 665 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 XXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 135 665 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 Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 136 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 137 665 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 XXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 138 665 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 XXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 140 665 6 Request for Override Pending 7 Special Handling 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 when it is necessary to justify the medical necessity of the level of ambulance services. If not required by this implementation guide, do not send. 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 0000000000 D DH 00000 XXXXX 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 144 665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 D XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 N 04 XXX XX XX XX Variants (all may be used) CRC Patient Condition Information: Vision CRC Homebound Indicator CRC EPSDT Referral 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 148 665 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 E2 N L2 XX XX XXX XX Variants (all may be used) CRC Ambulance Certification CRC Homebound Indicator CRC EPSDT Referral 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 149 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 Patient Condition Information: Vision CRC EPSDT Referral 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 151 665 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 AV XX XXX Variants (all may be used) CRC Ambulance Certification CRC Patient Condition Information: Vision CRC Homebound Indicator 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 152 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 153 665 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 | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_3 |
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 151 665 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 AV XX XXX Variants (all may be used) CRC Ambulance Certification CRC Patient Condition Information: Vision CRC Homebound Indicator 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 152 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 153 665 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 ABK X BF XXXXXX ABF XX BF XXX BF XXXXX BF XXXX XX BF XXXX BF XXXXXX BF XXXXXX ABF XXXXX BF XXXXX X ABF XX 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 Max use 1 Optional 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 154 665 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 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, 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 155 665 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-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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 156 665 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-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. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 157 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 158 665 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 159 665 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-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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 160 665 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, 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 161 665 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 XXXXX BO XXXXX Variants (all may be used) HI Health Care Diagnosis Code HI Condition 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. 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 162 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 163 665 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 XX BG XXXX BG XX BG XX BG XXXXXX BG XXXXX X BG XXXXX BG XXXXX BG XX BG XXXXXX BG XX BG XX Variants (all may be used) HI Health Care Diagnosis Code HI Anesthesia Related Procedure 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 164 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 165 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 166 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 167 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 168 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 11 0000000 0000000000000 X 000000000 XXXX 000 000000 T3 1 2 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 P3 1 XXX XX XXXXXX 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX XXXXX XXXX X 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 String (AN) Required Min 1 Max 60 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX XX Max use 1 Required N3-01 166 Laboratory | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_4 |
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 X 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 Code identifying the country subdivision Usage notes 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 183 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 G2 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX TE XXXXX EX XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX XXXX XXXXXX X 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 193 665 2310E Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX XXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 197 665 2310F Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 H 18 XX X 47 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) Required Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 CR XXX 00 0000000 XX 00000000000 00000 X 00 0 0000000000000 XX 0000000 00 XX 0000000000 00000 00000000 XXX 0000000000 0000000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 000000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 0000000000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 Y 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 returned in the remittance advice. If not required by this implementation guide, do not send. 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 00000000 XXX XXXX XXXXX X XXXXXX 0 00000 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 211 665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 2 XXXX XXXXX XXXX XXXXX II 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX XX XXX 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 216 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 219 665 (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_5 |
the country subdivision Usage notes 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 216 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX XX XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 222 665 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 Prior Authorization Number REF Other Payer Referral Number REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 XXX Variants (all may be used) REF Other Payer Secondary Identifier REF Other Payer Referral Number REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 Secondary Identifier REF Other Payer Prior Authorization Number REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 Secondary Identifier REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Claim Control Number 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 XXXXX Variants (all may be used) REF Other Payer Secondary Identifier REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Claim Adjustment Indicator 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 230 665 1 Person 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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. 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 G2 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 IV X XX XX XX XX XXX 0000000000 MJ 00000000 0 XX 0 00 0 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X DA 000000 0000000 000000000000000 4 If Rental Unit Price Indicator (SV5-06) is present, then DME Rental Price (SV5-04) is required 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 248 665 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 06 EL 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 249 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 250 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 251 665 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 AD 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 when CR102 is used. If not required by this implementation guide, do not send. 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 E DH 000 X 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 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 | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_6 |
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 AD 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 when CR102 is used. If not required by this implementation guide, do not send. 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 E DH 000 X 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 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 253 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 I MO 00000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 N 01 XXX XXX XXX XX Variants (all may be used) CRC Hospice Employee Indicator CRC Condition Indicator Durable Medical Equipment 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 257 665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 258 665 65 Open This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 259 665 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 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 260 665 Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 261 665 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 XX Variants (all may be used) DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date 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 - 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 262 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 263 665 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 XXXX Variants (all may be used) DTP Date - Service Date DTP DATE - Certification Revision Recertification Date 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 - 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 264 665 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 X Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date 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 - 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 265 665 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 XX Variants (all may be used) DTP Date - Service Date DTP Date - Prescription 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 - 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 266 665 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 XXXX Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date DTP Date - Begin Therapy Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 267 665 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 XXXXX Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last X-ray 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 268 665 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 XXXXX Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last X-ray 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 269 665 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 XXXXX Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date 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 - 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 739 D8 X Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date 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 - 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 00000000000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 R2 000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 01 000 000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 277 665 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 XXX Variants (all may be used) 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 REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 278 665 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 X Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) 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 REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 279 665 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 XXXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 280 665 receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 281 665 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 XXXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 282 665 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 Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Mammography Certification Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 283 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 284 665 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 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 Referral Number REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 285 665 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 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 Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 286 665 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 Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 287 665 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 XXXXX 2U XXXXX 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 Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 288 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 289 665 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 00000000000 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, 11:51 AM | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_7 |
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 XXXXX 2U XXXXX 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 Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 288 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 289 665 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 00000000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 290 665 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 00000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 DCP XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX 000000000000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 11 00000000 0000000000000 XXXXXX 00000000 XXX XXX 000 WK XXX UN 0000000 T6 5 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 0000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XZ XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 303 665 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 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 XXXX X XXXXX XXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX XX XXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X X 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XX XXXXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 316 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 LU XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX XXX XX XXXXXX XX XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX XXX XXX XXXXXX XX XXXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X XXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XX XXXXXXX XXX Only one of Ordering Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_8 |
DK 1 XX XXX XXX XXXXXX XX XXXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X XXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XX XXXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 327 665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 1G XX 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X FX X TE XXXXX EM XXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XX XXXXXX XXXX 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 G2 XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XX XXXXXXXX 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 339 665 2420G Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX X 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 343 665 2420H Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX 00000000 IV XX XX XX XX XX XXXX 0000 000 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX 0000000 00 XXXX 0000000000 0000000000 00 XX 00000000000 000000000000000 XXX 00000000000 00 00 XXXXX 0 000000 XXXXX 000000000000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX If Code List Qualifier Code (LQ-01) is present, then Form Identifier (LQ-02) is required 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX Y XX 20250131 00000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 357 665 0 No Subordinate HL Segment in This Hierarchical Structure. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 39 D8 XXX 01 000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X XXXX XXXXXX 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX X 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX 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 | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_9 |
been taken 01 Actual Pounds PAT-08 81 Patient Weight Min 1 Max 10 Decimal number (R) Optional 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X XXXX XXXXXX 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX X 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX EX XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 C Y Y P AA XXX XX XXX 03 15 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 374 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 376 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 378 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 - Disability Dates DTP Date - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 382 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 314 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 - Discharge DTP Date - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 - Hearing and Vision Prescription Date DTP Date - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 386 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 388 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 389 665 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 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 390 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 391 665 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 - Last Menstrual Period DTP Date - Initial Treatment Date 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 392 665 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 393 665 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 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 - Onset of Current Illness or Symptom 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 394 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 395 665 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 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 396 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 397 665 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 398 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 399 665 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 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked 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 | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_10 |
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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 398 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 399 665 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 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 - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 400 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 402 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - Last Menstrual Period DTP Date - Onset of Current Illness or Symptom DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last Worked DTP Date - Last X-ray Date 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 404 665 Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 PQ 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 05 00000000000000 00000 XXX 00 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 00000000000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 411 665 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 XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 412 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 413 665 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 XXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 414 665 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 XXXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 415 665 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 Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 416 665 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 X Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 417 665 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 XXXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 418 665 The value carried in this element is limited to a maximum of 20 positions. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 421 665 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 Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 422 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 423 665 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 XXXXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 424 665 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 Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 425 665 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 426 665 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 Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 427 665 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 XXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 Clinical Laboratory Improvement Amendment (CLIA) Number REF Adjusted Repriced Claim Number REF Care Plan Oversight REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Claim Identifier For Transmission Intermediaries REF Mammography Certification Number REF Mandatory Medicare (Section 4081) Crossover Indicator REF Prior Authorization REF Payer Claim Control Number REF Referral Number REF Repriced Claim Number REF Medical Record 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 429 665 6 Request for Override Pending 7 Special Handling 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 when it is necessary to justify the medical necessity of the level of ambulance services. If not required by this implementation guide, do not send. 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 0000000000 C DH 00000000 XXXX 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 433 665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 E XX XXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 01 XXX XXX XX XX Variants (all may be used) CRC Patient Condition Information: Vision CRC Homebound Indicator CRC EPSDT Referral 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 437 665 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 E3 N L3 XX XX XXX XXX Variants (all may be used) CRC Ambulance Certification CRC Homebound Indicator CRC EPSDT Referral 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 438 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 439 665 CRC 2200 Detail | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_11 |
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 437 665 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 E3 N L3 XX XX XXX XXX Variants (all may be used) CRC Ambulance Certification CRC Homebound Indicator CRC EPSDT Referral 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 438 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 Patient Condition Information: Vision CRC EPSDT Referral 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 440 665 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 S2 XX XX Variants (all may be used) CRC Ambulance Certification CRC Patient Condition Information: Vision CRC Homebound Indicator 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 441 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 442 665 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 ABK XXXXX ABF XX ABF XX ABF XXXX BF XXXX ABF X XXXXX BF XXXX BF XXXXX BF XXXXX ABF XXXXX ABF X X BF XXXX 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 Max use 1 Optional 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 443 665 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 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, 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 444 665 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-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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 445 665 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-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. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 446 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 447 665 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 448 665 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-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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 449 665 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, 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 450 665 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 X Variants (all may be used) HI Health Care Diagnosis Code HI Condition 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. 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 451 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 452 665 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 XX BG X BG XXX BG XXXXXX BG XXX BG XXXXXX B G XXXXX BG XXXX BG XXXX BG XX BG X BG XXXX Variants (all may be used) HI Health Care Diagnosis Code HI Anesthesia Related Procedure 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 453 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 454 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 455 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 456 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 457 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 10 00000000000 00 X 00000000 XXXX 000000000 T3 2 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XXXX XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XX XXX 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 2 Non-Person Entity NM1-03 1035 Rendering Provider Last or Organization Name String (AN) Required Min 1 Max 60 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_12 |
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX XX XXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 472 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXX TE XXXX EX XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX XX XXXX XXX XX XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX XX XXXXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 482 665 2310E Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XX XXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 486 665 2310F Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 H 53 XXXX X 41 MA 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 CO X 000000000000 000 XXX 00000 000 XXX 00000 0000 00 XXX 00 00000 X 000000000000000 000 XXXX 0 00000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 0000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 00 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 Y 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 returned in the remittance advice. If not required by this implementation guide, do not send. 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 0000000000000 X XXXXX XXXX XX XXXXX 0000000 00000000 000000 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 500 665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX XXXXXX XXX X 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XXXX 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) | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_13 |
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 XXXXXX XXXXXX XXX X 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX XX XXXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 505 665 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX PI 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX X 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XX XXXXXXXX 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 511 665 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 XXXXX Variants (all may be used) REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 XXX Variants (all may be used) REF Other Payer Secondary Identifier REF Other Payer Referral Number REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 Secondary Identifier REF Other Payer Prior Authorization Number REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 Secondary Identifier REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Claim Control Number 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 Secondary Identifier REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Claim Adjustment Indicator 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 519 665 1 Person 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 G2 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 522 665 1 Person 2 Non-Person Entity 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 1G 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 G2 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. 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 529 665 1 Person 2 Non-Person Entity 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 LU X 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 WK XX XX XX XX XX XXXXXX 0000000 MJ 0000 XX 0 0 0 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX DA 0000000000000 00000000000 000000000 0000 6 If Rental Unit Price Indicator (SV5-06) is present, then DME Rental Price (SV5-04) is required 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 538 665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 OB FT AC XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_14 |
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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 538 665 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 OB FT AC XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 540 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 541 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 542 665 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 NS 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 when CR102 is used. If not required by this implementation guide, do not send. 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 000 C DH 000 XXX 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 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 544 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 I MO 00000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 Y 06 XXX XX XX XXX Variants (all may be used) CRC Hospice Employee Indicator CRC Condition Indicator Durable Medical Equipment 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 549 665 65 Open This code value is a placeholder to satisfy the Mandatory Data Element syntax requirement. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 38 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 551 665 Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - 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 XXXXXX Variants (all may be used) DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date 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 - 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 553 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - 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 XX Variants (all may be used) DTP Date - Service Date DTP DATE - Certification Revision Recertification Date 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 - 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - 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 XX Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date 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 - 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - 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 XXXXXX Variants (all may be used) DTP Date - Service Date DTP Date - Prescription 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 - 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - 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 - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date DTP Date - Begin Therapy Date DTP Date - Last Certification Date DTP Date - Last Seen Date DTP Date - Last X-ray 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - 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 XXX Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Seen Date DTP Date - Last X-ray 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - 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 - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last X-ray 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 560 665 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 X Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date DTP Date - Begin Therapy Date DTP Date - Initial Treatment Date DTP Date - Last Certification Date DTP Date - Last Seen 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date 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 - 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 739 D8 X Variants (all may be used) DTP Date - Service Date DTP Date - Prescription Date DTP DATE - Certification Revision Recertification Date 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 - 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 0 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 0000000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 R2 00000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 06 000000000000 00 XXX 000000 XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 XXXXX Variants (all may be used) 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 REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 XXXXX Variants (all may be used) REF Clinical Laboratory Improvement Amendment (CLIA) 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 REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Mammography Certification Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 571 665 receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 572 665 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 Clinical Laboratory Improvement Amendment (CLIA) Number REF Immunization Batch Number REF Line Item Control Number REF Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 XX 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 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 574 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 575 665 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 XX Variants | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_15 |
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 XX 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 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 574 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 575 665 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 XX 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 Referral Number REF Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 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 Adjusted Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 577 665 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 Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Prior Authorization 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 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 Referral Number REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification REF Repriced Line Item Reference Number REF Adjusted 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 579 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 00000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 DCP XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X 00000000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 13 0000000 0 XXX 0000 XXX 000000000000000 E R XXXXXX MJ 000000000000000 T2 1 3 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 N4 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 00000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XXX XXXX 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 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX 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. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 607 665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX 2U XXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X XXXXX X XXXXX 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_16 |
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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 X XXXXX X XXXXX 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 G2 XXX 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX XXXXXX XXXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX XX XXXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 618 665 Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX FX X FX 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 DN 1 XX XXX XX XXX 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. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 1G 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXXX XX XXXXXX 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 630 665 2420G Ambulance Pick-up Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XX XX XXX 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 634 665 2420H Ambulance Drop-off Location Loop end Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 000 HC XXX XX XX XX XX XX 00000000000 00 0 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 CO XXX 0000000000 0000000000000 XXXX 00000000 0000000 00000 XX 00000000000000 000 XX 0000000000 00 0000 XXXXX 00000000 0000 XXXXX 000000000000 00 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 639 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 640 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 641 665 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 000000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 UT XX If Code List Qualifier Code (LQ-01) is present, then Form Identifier (LQ-02) is required 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX W XXXX 20250131 0 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 | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_17 |
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 XX If Code List Qualifier Code (LQ-01) is present, then Form Identifier (LQ-02) is required 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 XXXXX W XXXX 20250131 0 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 648 665 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 0000 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 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 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 650 665 EDI Samples Example 1: Commercial Health Insurance ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1408 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 140840 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 651 665 Example 10a: Drug administered in the Physician Office ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1411 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 141104 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 652 665 Example 11: PPO Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1415 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 141535 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 653 665 Example 12: Out of Network Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1416 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 141631 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 654 665 Example 2: Encounter ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1418 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 141815 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 655 665 Example 3a: Claim from Billing Provider to Payer A ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1420 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142058 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 656 665 SE 52 0021 GE 1 000000001 IEA 1 000000001 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 657 665 Example 4: Medicare Secondary Payer (COB) ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1421 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142142 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 658 665 Example 5: Ambulance ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1422 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142212 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 659 665 SE 52 000017712 GE 1 000000001 IEA 1 000000001 1 30 25, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 660 665 Example 6: Chiropractic ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1422 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142242 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 661 665 Example 7: Oxygen ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1423 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142340 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 663 665 Example 8: Wheelchair ISA 00 00 ZZ SENDER ZZ RECEIVER 231106 1424 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142406 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 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 231106 1424 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231106 142432 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, 11:51 AM X12 HIPAA 837 Health Care Claim: Professional (X222A2) - Stedi EDI Guides https: www.stedi.com app guides view hipaa health-care-claim-professional-x222a2 01GRYB6EJ999Y6MZ53ZBAHYBHE 665 665 | /kaggle/input/edi-db-835-837/X12 HIPAA 837 Health Care Claim_ Professional.pdf | a3c57b6fc29ac1e7724e4027d5ef0720 | a3c57b6fc29ac1e7724e4027d5ef0720_18 |
CarePartners of Connecticut 837 COMPANION GUIDE HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version 005010 Instructions Related to 837 Healthcare Institutional Professional Claims Transactions Based on ASC X12 Implementation Guides, Version 005010 October 2018 CarePartnersCT Standard 837 Companion Guide Disclosure Statement The information in this document is subject to change. Changes will be posted via the CarePartners of Connecticut website located at: www.carepartnersct.com This template is Copyright 2010 by The Workgroup for Electronic Data Interchange (WEDI) and the Data Interchange Standards Association (DISA), on behalf of the Accredited Standards Committee (ASC) X12. 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 CarePartners of Connecticut is accepting X12 837 Institutional (837I) X12 837 Professional (837P) Health Care Claims, as mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The X12 837I and 837P versions of the 5010 Standards for Electronic Data Interchange Technical Report Type 3 and Errata (also referred to as Implementation Guides) for the Health Care Institutional and Professional Claims has been established as the standard for Health Care claims transaction compliance. This document has been prepared to serve as a CarePartners of Connecticut specific companion guide to the 837I and 837P Transaction Sets. This document supplements but does not contradict any requirements in the 837 I P Technical Report, Type 3. The primary focus of the document is to clarify specific segments and data elements that should be submitted to CarePartners of Connecticut on the 837 Institutional Professional Claim Transactions. This document will be subject to revisions as new versions of the 837 Institutional Professional Health Care Claim Transaction Set Technical Reports are released. This document has been designed to aid both the technical and business areas. It contains CarePartners of Connecticut specifications for the transactions as well as contact information and key points CarePartnersCT Standard 837 Companion Guide Table Of Contents 1 INTRODUCTION.................................................................................................................................................................... 4 SCOPE............................................................................................................................................................................................... 4 OVERVIEW........................................................................................................................................................................................ 4 REFERENCES..................................................................................................................................................................................... 4 2 GETTING STARTED................................................................................................................................................................ 5 WORKING WITH CAREPARTNERS OF CONNECTICUT........................................................................................................................ 5 TRADING PARTNER REGISTRATION.................................................................................................................................................. 5 3 TESTING WITH THE PAYER..................................................................................................................................................... 6 4 CONNECTIVITY WITH THE PAYER COMMUNICATIONS........................................................................................................... 6 TRANSMISSION ADMINISTRATIVE PROCEDURES............................................................................................................................. 6 Direct Submitters......................................................................................................................................................................... 6 RE-TRANSMISSION PROCEDURE.................................................................................................................................................. 6 COMMUNICATION PROTOCOL SPECIFICATIONS.............................................................................................................................. 7 PASSWORDS..................................................................................................................................................................................... 9 MAINTENANCE SCHEDULE............................................................................................................................................................. 10 RULES OF BEHAVIOR...................................................................................................................................................................... 10 5 CONTACT INFORMATION................................................................................................................................................... 10 6 CONTROL SEGMENTS ENVELOPES....................................................................................................................................... 10 SETUP FOR 837 INBOUND TRANSACTIONS............................................................................................................................................. 11 ISA-IEA....................................................................................................................................................................................... 11 IEA - Interchange Control Trailer Segment................................................................................................................................. 12 GS-GE - Functional Group Header Segment................................................................................................................................ 12 Group Trailer.............................................................................................................................................................................. 13 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS........................................................................................................... 12 BUSINESS SCENARIOS........................................................................................................................................................................... 12 FREQUENTLY ASKED QUESTIONS............................................................................................................................................................ 14 GENERAL CLAIM QUESTIONS................................................................................................................................................................. 14 CAREPARTNERS OF CONNECTICUT PRODUCT TYPE QUESTIONS..................................................................................................................... 15 DIRECT 837 CLAIMS QUESTIONS............................................................................................................................................................ 15 ELECTRONIC FUNDS TRANSFER.............................................................................................................................................................. 15 8 ACKNOWLEDGEMENTS AND OR REPORTS..................................................................................................................... 15 ACKNOWLEDGEMENTS......................................................................................................................................................................... 15 9 TRADING PARTNER AGREEMENTS.................................................................................................................................. 18 TRADING PARTNERS....................................................................................................................................................................... 18 10 TRANSACTION SPECIFIC INFORMATION......................................................................................................................... 18 005010X223A2 HEALTH CARE CLAIM: INSTITUTIONAL............................................................................................................................. 19 005010X222A1 HEALTH CARE CLAIM: PROFESSIONAL............................................................................................................................. 21 APPENDICES.......................................................................................................................................................................... 30 A - EDI SET UP FORM......................................................................................................................................................................... 30 B - TRANSACTION EXAMPLES................................................................................................................................................................. 31 837 Institutional Claim Sample:................................................................................................................................................. 31 837 Professional Claim Sample:................................................................................................................................................. 32 C - CHANGE SUMMARY......................................................................................................................................................................... 32 CarePartnersCT Standard 837 Companion Guide 1 INTRODUCTION In order to submit a valid transaction, please refer to the National Electronic Data Interchange Transaction Set Technical Report Errata for the Health Care Claim: Institutional ASC X12N 837 (005010X223, 005010X223A1 005010X223A2) and The Health Care Claim: Professional ASC X12N 837 (005010X222 005010X222A1). The Technical Reports can be ordered from the Washington Publishing Company s website at www.wpc-edi.com. For questions relating to the CarePartners of Connecticut 837 Institutional Claim Transaction, and the 837 Professional Claim Transaction, or testing, please contact the EDI Operations Department at 888-631-7002, Ext. 52994 or email your questions to EDI_CT_Operations carepartnersct.com. CarePartners of Connecticut billing guidelines are not included in this document. Please refer to our website at http: www.carepartnersct.com for these guidelines, or contact Provider Services at 888-341-1508. Please note, CarePartners of Connecticut is not responsible for any software utilized by the submitter for the creation of an ASC X12 837I or ASC X12 837P transactions. SCOPE The transaction instruction component of this companion guide must be used in conjunction with an associated ASC X12 Implementation Guide. The instructions in this companion guide are not intended to be stand-alone requirements documents. This companion guide conforms to all the requirements of any associated ASC X12 Implementation Guides and is in conformance with ASC X12 s Fair Use and Copyright statements. OVERVIEW The Health Insurance Portability and Accountability Act Administration Simplification (HIPAA-AS) requires CarePartners of Connecticut and all other covered entities to comply with the electronic data interchange standards for health care as established by the Secretary of Health and Human Services. This guide is designed to help those responsible for testing and setting up electronic claim submission transactions. Specifically, it documents and clarifies when situational data elements and segments must be used for reporting and identifies codes and data elements that do not apply to CarePartners of Connecticut. This guide supplements (but does not contradict) requirements in the ASC X12 837 (version 005010X223 and 005010X223A1 A2) or the ASC X12 837 (005010X222 005010X222A1) implementation. This information should be given to the provider s business area to ensure that healthcare claim status responses are interpreted correctly. REFERENCES The ASC X12 837 (version 005010X222A1 and 005010X223A2) Implementation Guide for HealthCare Claim Transaction has been established as the standard for claim submission transactions and is available at http: www.wpc-edi.com. CarePartners of Connecticut Web site containing documentation on transactions for providers is located at www.carepartnersct.com. CarePartners of Connecticut Web site containing documentation on e-transactions for providers is located at https: www.carepartnersct.com for-providers provider-resource-center CarePartnersCT Standard 837 Companion Guide 2 GETTING STARTED WORKING WITH CAREPARTNERS OF CONNECTICUT This section describes how to interact with CarePartners of Connecticut EDI Department. For questions relating to the CarePartners of Connecticut 837 Health Care Transactions or testing, contact the EDI Operations Department at 888-631-7002, Ext. 52994 or e-mail your questions to: EDI_CT_Operations carepartnersct.com TRADING PARTNER REGISTRATION This section describes how to register as a trading partner with CarePartners of Connecticut. By contacting the EDI Operations group, the Trading partner will be sent a File Exchange Request Form to fill out and return to EDI Operations. EDI Operations will then assign a Submitter ID to use in your transactions. The trading partner will then be set up in CarePartners of Connecticut testing environment and the information is sent back to the trading partner so they may begin testing. CarePartnersCT Standard 837 Companion Guide 3 TESTING WITH THE PAYER EDI Operations will work with the new submitter to setup a username and password. After establishing a username and password, the submitter can begin sending claim transactions to the test environment. 1. During the testing process, EDI Operations examines submitted test transactions for required elements. EDI Operations also ensures that the submitter gets a response during the testing mode. Submitters are encouraged to review their 999s and 277CA reports for errors. 2. EDI Operations notifies the submitter upon the successful completion of testing. 3. When the submitter is ready to send an 837 transaction to the production mailbox, they are notified by EDI Operations, and given a GO LIVE date to move to the production environment. 4. The submitter's username remains the same when moving from test to production. 5. CarePartners of Connecticut recommends each test file includes no more than 100 claims. 4 CONNECTIVITY WITH THE PAYER COMMUNICATIONS TRANSMISSION ADMINISTRATIVE PROCEDURES Direct Submitters Providers interested in submitting electronic claim transactions should contact EDI Operations at CarePartners of Connecticut via email or telephone to request setup. Please refer to section 5 for contact details. A direct submitter EDI setup form can be found in Appendix A- EDI Set-up Form section. EDI Operations will coordinate the appropriate process to set up the electronic data interchange. This includes completing enveloping requirements as indicated in the Communications Connection, section 4. Upon setup completion, EDI Operations notifies the submitter and reviews the testing procedures. After this review, test claim files can be sent to CarePartners of Connecticut. Upon successful testing between CarePartners of Connecticut and the new submitter, the submitter migrates to a production status. RE-TRANSMISSION PROCEDURE CarePartners of Connecticut currently supports re-transmission of transactions, once any errors have been corrected. Please refer to your 999 and 277CA acknowledgement reports for details. CarePartnersCT Standard 837 Companion Guide COMMUNICATION PROTOCOL SPECIFICATIONS This section describes CarePartners of Connecticut communication protocol(s). The following is a list of technical standards and versions for the HTTP MIME Multipart envelope and eligibility payload: HTTP Version 1.1 SOAP Version 1.2 TLS v1.2 Health Care Institutional Professional Claims Transactions - Version 005010X223A2 - 005010X222A1 CAQH MIME CarePartners of Connecticut supports the use of HTTP MIME Multipart existing envelope standards and has implemented the HTTP MIME Multipart envelope standards as identified in CAQH CORE Phase IV Connectivity standards. Please refer to: (https: www.caqh.org sites default files 470_Connectivity_Rule_0_0.pdf). The following is a list of technical standards and versions for the HTTP MIME Multipart envelope and eligibility payload: HTTP Version 1.1 TLS v1.2 MIME Version 1.0 Health Care Institutional Professional Claims Transactions - Version 005010X223A2 - 005010X222A1 CAQH SOAP CarePartners of Connecticut supports the use of HTTP SOAP WSDL envelope standards as identified in CAQH CORE Phase IV Connectivity standards. Please refer to: (https: www.caqh.org sites default files 470_Connectivity_Rule_0_0.pdf). CarePartners of Connecticut provides certificates to use in place of a user ID and password for SOAP upon completion of enrollment process. CarePartnersCT Standard 837 Companion Guide Message specifications for SOAP Batch Transactions Batch Submit Transaction Envelope Element Specification PayloadType X12_837_Request_005010X223A2 X12_837_Request_005010X222A1 ProcessingMode Batch PayloadID Unique UUID PayloadLength Required CheckSum Checksum for MIME Attached Payload Payload cid of base64 encoded MIME Attachment SenderID ISA06 value as assigned by CarePartners of Connecticut ReceiverID 16307 CORERuleVersion 4.0.0 Certificate Version X.509 Batch Submit AckRetrieval Transaction Envelope Element Specification PayloadType X12_999_RetrievalRequest_005010X231A1 ProcessingMode Batch PayloadID Unique UUID of Inbound 837 SenderID ISA06 value 16307 ReceiverID ISA08 value as assigned by CarePartners of Connecticut CORERuleVersion 4.0.0 Certificate Version X.509 CarePartnersCT Standard 837 Companion Guide Batch Results Retrieval Transaction Envelope Element Specification PayloadType X12_277CA_Request_005010X214 ProcessingMode Batch PayloadID Unique UUID of Inbound 837 SenderID ISA06 value 16307 ReceiverID ISA08 value as assigned by CarePartnersCT CORERuleVersion 4.0.0 Certificate Version X.509 Batch Results AckSubmit Transaction (Optional) Envelope Element Specification PayloadType X12_999_SubmissionRequest_005010X231A1 ProcessingMode Batch PayloadID Unique UUID of Inbound 837 SenderID ISA06 value as assigned by CarePartners of Connecticut ReceiverID 16307 CORERuleVersion 4.0.0 Certificate Version X.509 Note: Changes to CAQH that occur after the writing of this document will override this document. PASSWORDS Password assignment and resets are done by the EDI Operations group, (See Contact Information below in section 5.) CarePartnersCT Standard 837 Companion Guide MAINTENANCE SCHEDULE The systems used for 837 transactions have a standard maintenance schedule of Sunday 8PM to 12AM EST. The systems are unavailable during this time. Email notifications will be sent notifying submitters of unscheduled system outages. RULES OF BEHAVIOR Rules of Behavior for programs that connect to this site: - Unauthorized use of certificates is not permitted - Must not deliberately submit batch files that contain Viruses. 5 CONTACT INFORMATION The following sections provide contact information for any questions regarding HIPAA, 837 transactions, EDI, documentation, or training. For 837 Transaction Questions The following table provides specific contact information by department and responsibility. For Questions Regarding Contact Phone Number Email Address EDI Claims Submission (i.e., file submissions, claim rejections) CarePartners of Connecticut EDI Operations 888-631-7002, Ext. 52994 EDI_CT_Operations carepartnersct.com Claim Information (i.e., claim denials, payment policies) CarePartners of Connecticut Provider Services 888-341-1508 NPI registration and credentialing CarePartners of Connecticut Provider Information 888-880-8699 Ext. 43153 Applicable Websites E-MAIL This section contains detailed information about useful web sites and email addresses. http: www.wpc-edi.com for corrected examples http: www.carepartnersct.com providers 6 CONTROL SEGMENTS ENVELOPES Envelope Identifiers CarePartners of Connecticut supplies each submitting provider with the Submitter and Sender Identifiers for the envelope elements as a part of the setup process. The Interchange Receiver and Application Receiver IDs depend upon which e-Channel is used. For other e-Channels: The Interchange Receiver ID (ISA08) is 16307 and the Application Receiver ID (GS03) is 16307 CarePartnersCT Standard 837 Companion Guide Setup for 837 INBOUND Transactions ISA-IEA This section describes CarePartners of Connecticut use of the interchange control segments. It includes a description of expected sender and receiver codes, authorization information, and delimiters ISA - Interchange Control Header Segment Segment Name Seg. ID Req Opt of Char Value Remarks Authorization Information Qualifier ISA01 R 2 00 00 - No Authorization Information Present Authorization Information ISA02 R 10 spaces No Authorization Information Present Security Information Qualifier ISA03 R 2 00 00 - No Security Information Present Security Information Password ISA04 R 10 spaces No Security Information Present Interchange ID Qualifier Qualifier for Trading Partner ID ISA05 R 2 ZZ Sender Qualifier - Mutually Agreed. Interchange Sender ID Trading Partner ID ISA06 R 15 SENDER ID Sender s Identification Number Interchange ID Qualifier Qualifier for CarePartners of Connecticut ID ISA07 R 2 33 National Association of Insurance Commissioner s Company Code is being used. Interchange Receiver ID CarePartners of Connecticut ID ISA08 R 15 16307 CarePartners of Connecticut - NAIC number: 16307 Interchange Date ISA09 R 6 YYMMDD Date of the interchange in YYMMDD format Interchange Time ISA10 R 4 HHMM Time of the interchange in HHMM format Repetition Separator ISA11 R 1 (is a typical separator received) 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 Interchange Control Version Number ISA12 R 5 00501 Version number Interchange Control Number Last Control Number ISA13 R 9 Auto- generated Assigned by the interchange sender, must be associated with IEA02 segment Acknowledgement Request ISA14 R 1 0 0 - No Acknowledgement Requested Usage Indicator ISA15 R 1 T or P T-test data; P-production data Separator ISA16 R 1 Any ASCII Value. Component element separator CarePartnersCT Standard 837 Companion Guide IEA - Interchange Control Trailer Segment This segment defines the end of an interchange of zero or more functional groups and interchange-related control segments. The Input Data column below contains text entered in bracketed italics indicates special input data dependent on sender, time, date, etc. Elements Size Name Input Data Remarks IEA01 1 5 Number of Included Functional Groups Submitter-specific ID number A count of the number of functional groups included in an interchange. IEA02 9 Interchange Control Number Submitter-specific ID number A control number assigned by the interchange sender. GS-GE - Functional Group Header Segment This section describes CarePartners of Connecticut 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 CarePartners of Connecticut expects functional groups to be sent and how CarePartners of Connecticut will send functional groups. These discussions will describe how similar transaction sets will be packaged and CarePartners of Connecticut use of functional group control numbers. Segment Name Seg. ID Req Opt of Char Value Remarks Functional Identifier Code GS01 R 2 HC Health Care Claim. Application Sender s Code GS02 R 2 15 CarePartners of Connecticut Submitter ID Code identifying party sending transmission Application Receiver s Code GS03 R 2 15 16307 Code identifying party receiving transmission. National Association of Insurance Commissioner s Company Code is being used. Date GS04 R 8 CCYYMMDD Functional Group creation date in CCYYMMDD format Time GS05 R 4 8 HHMM Functional Group creation time in HHMM format. Time expressed in 24-hour clock. For example, 3:23 PM is entered as 1523. Group Control Number GS06 R 1 9 Assigned and maintained by the sender, must be associated with GE02 segment GS06 Responsible Agency Code GS07 R 1 2 X Accredited Standards Committee X12 Version Release Industry Identifier Code GS08 R 1 12 005010X223A2 or 005010X222A1 Health Care Claim for Institutional Health Care Claim for Professional. CarePartnersCT Standard 837 Companion Guide Group Trailer Segment Name Seg. ID Req Opt of Char Value Remarks Number of Transaction Sets Included GE01 R 1 6 1 Total number of transactional sets included in the functional group or interchange Group Control Number GE02 R 1 9 Assigned number originated and maintained by the sender CarePartnersCT Standard 837 Companion Guide 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS Business Scenarios Please refer to the business scenarios presented in the Implementation Guides or visit http: www.wpc-edi.com 837 for additional or corrected examples. Category 1: General Instructions All NPIs on claims submitted to CarePartners of Connecticut must be registered with the Provider Information Department prior to transmission. Please call 888-880-8699 Ext. 43153 to verify or register the NPIs of your organization. CarePartners of Connecticut will require a valid NPI when NM109 is used in any provider loop and will not accept Provider Secondary Identification as the primary identifier of that provider. New submitters must go through the appropriate set-up authorization process in order to transmit electronic claims with CarePartners of Connecticut. Please refer to the Communications Connectivity Component of this document for details. CarePartners of Connecticut will accept 837 Institutional and 837 Professional Claim Transactions for all business products, however the 837 Institutional and 837 Professional claim files must be sent separately. They cannot be sent on the same file. As stated in the technical reports, a maximum of 5000 CLM segments will be accepted by CarePartners of Connecticut. CarePartners of Connecticut is adhering to structural specifications for required and situational fields as stated in the technical reports. If the incoming 837I or 837P has a single ST SE and the structure does not comply, the entire file will fail in the validation process. If the incoming 837I or 837P has multiple ST SEs, only the failed ST SEs in the file will fail in the validation process. The submitter receives a 999 acknowledgement for notification of the ST SEs that failed. CarePartners of Connecticut will capture payee information from the Billing Provider Name loop (Loop 2010AA). The Pay-To Address Name loop (Loop 2010AB) in 5010 has been changed to enter a separate billing provider address where payments should be sent. Please note that CarePartners of Connecticut will continue making payments to the address on record in our backend system database instead of the addresses submitted in loop 2010AB. CarePartners of Connecticut cannot currently support billing for atypical provider type submissions. For Frequency Types 5, 7, and 8, (Element CLM05-3), CarePartners of Connecticut s original claim number (Original Reference Number Element REF02) must be submitted as stated in the technical report. We also strongly recommend sending the Original Reference Number with Frequency Types 2, 3, and 4. CarePartnersCT Standard 837 Companion Guide When contacting CarePartners of Connecticut with questions for claims with Frequency Types 2, 3, 4, 5, 7, and 8, (Element CLM05-3), please use the original claim number even though a new claim number for that submission may be assigned. The CarePartners of Connecticut implementation of Coordination of Benefits (COB) Information utilizes claim header information in the COB Header Other Subscriber Information (Loop 2320), Other Subscriber Name (Loop 2330A), and Other Payer Name (Loop 2330B) as well as line level information in the Line Adjudication Information Details (Loop 2430) within the 837 transactions. We strongly recommend closely reviewing these loops in the technical reports before submitting COB information. Many data segments have been changed or deleted. Although the HIPAA Transaction Set technical report allows the repeating of Billing Provider Name loop (2010AA Loop) for each claim, the size of transmission files can be reduced by up to 20 by using only one repeat of Billing Provider Name loop followed by all subscriber and claim information for that Provider. Transmission files can be further reduced by grouping the claims of each subscriber together. CarePartners of Connecticut only accepts ICD-10 Codes. For compliance purposes, CarePartners of Connecticut will only accept qualifier MJ for minutes when billing anesthesia procedure codes. UN is a valid qualifier for procedures other than anesthesia. Due to system limitations, CarePartners of Connecticut is unable to accept claims submitted electronically where charges total one million dollars or more. Each CarePartners of Connecticut member is uniquely identified by his or her member ID. All members should be considered as subscribers, and providers should submit member ID in Element NM109 of Loop 2010BA. CarePartners of Connecticut will not accept any data in the Patient Loop (2000C) and will REJECT accordingly. CarePartnersCT Standard 837 Companion Guide Frequently Asked Questions General Claim Questions Q. Who do I contact for setup issues? A. Contact EDI Operations, EDI_CT_Operations carepartnersct.com, for all setup issues. Q. Is there an EDI setup form? A. Yes, you can find the EDI setup form on the CarePartners of Connecticut Web site (www.carepartnersct.com) or in this guide, (see appendix A-EDI Set-up Form). Q. What is CarePartners of Connecticut s Payer ID? A. Contact EDI Operations by sending email to: EDI_CT_Operations carepartnersct.com to obtain CarePartners of Connecticut Payer ID number. It is important to make sure your NPI is on file at CarePartners of Connecticut and that you are set up to submit claims via a clearinghouse. Q. Is My NPI on file at CarePartners of Connecticut? A. To determine if your NPI is on file, contact our Provider Information Department, 888- 880-8699 Ext.43153. Q. Is there an NPI registration form? A. Yes, you can find the NPI registration form on the CarePartners of Connecticut Web site. It is located at: https: www.carepartnersct.com for-providers provider-resource-center Q. What should I do if I change Clearinghouses? A. If you change your clearinghouse, please inform EDI Operations by sending email to: EDI_CT_Operations carepartnersct.com. Q. How do I add or delete payees? A. Contact EDI Operations by sending an email to EDI_CT_Operations carepartnersct.com to add or delete payees. Q. Can I send paper claims? A. Yes. However CarePartners of Connecticut strongly recommends electronic claims submission; when sending paper claims, you must clearly print paper claims on original CMS 1500 or UB04 RED forms. Q. Will CarePartners of Connecticut accept a P.O. Box or Lock Box in Loop 2010AA? A. No, P.O. Boxes or Lock Boxes are not allowed in loop 2010AA per the Implementation Guides and claims that contain them will be rejected. As specified in the Implementation Guides, P.O. Box or Lock Box information can be sent in loop 2010AB, Pay-To Address Name, if necessary. However, CarePartners of Connecticut uses the address of record that we have on file. Q. Will CarePartners of Connecticut accept a 5-digit zip code in loop 2010AA? A. No, per the Implementation Guides, only 9-digit zip codes can be accepted. If the claim contains a 5-digit zip code, the claim will be rejected. CarePartnersCT Standard 837 Companion Guide CarePartners of Connecticut Product Type Questions Q. Can I send all CarePartners of Connecticut product types in one electronic file? B. Yes, all products can be submitted in one file. However, the 837 Institutional and 837 Professional claim files must be sent separately. They cannot be sent on the same file. Direct 837 Claims Questions Q. Is testing required to send 837 claims to CarePartners of Connecticut? A.Yes. Please refer to section 3 in this Companion Guide for testing process details. Q. For how long are 277CA Acknowledgement reports available? A. The 277CA Acknowledgement reports are retained in your mailbox for one week. Electronic Funds Transfer Q. Does CarePartners of Connecticut offer electronic funds transfer (EFT)? A. CarePartners of Connecticut offers EFT through our partnership with PaySpan Health. Go to the PaySpan Health website at www.payspanhealth.com. A step-by-step registration guide is available online. If you need additional assistance or have questions concerning EFT, please contact PaySpan. Send an email to providersupport payspanhealth.com or call the Provider Support Team at 877.331.7154, option 1. Provider Support Specialists are available to assist Monday through Friday from 8am to 8pm, Eastern Time. Registration with PaySpan is available after the first claim a provider has submitted is adjudicated and paid by CarePartners of Connecticut. The first payment will be in the form of a paper check that will contain the registration instructions 8 ACKNOWLEDGEMENTS AND OR REPORTS Acknowledgements CarePartners of Connecticut will send an acknowledgement for each 837 transaction sent with the 277CA Health Care Claim Acknowledgment (See 277CA Companion Guide). CarePartners of Connecticut will return the 999 IMPLEMENTATION ACKNOWLEDGMENT FOR HEALTH CARE INSURANCE as per the Technical Report, Type 3. The standard format is below. ST Transaction Set Header AK1 Functional Group Response Header LOOP ID - 2000 - AK2 TRANSACTION SET RESPONSE HEADER AK2 Transaction Set Response Header LOOP ID - 2100 - AK2 IK3 ERROR IDENTIFICATION IK3 Error Identification CTX Segment Context CarePartnersCT Standard 837 Companion Guide CTX Business Unit Identifier LOOP ID - 2110 - AK2 IK3 IK4 IMPLEMENTATION DATA ELEMENT NOTE IK4 Implementation Data Element Note CTX Element Context IK5 Transaction Set Response Trailer AK9 Functional Group Response Trailer SE Transaction Set Trailer Present On Admission (POA) Indicators Provider Types Affected Hospitals who submit claims to fiscal intermediaries (FI) or Medicare Part A B Administrative Contractors (A B MACs) for Medicare beneficiary inpatient services. CarePartners of Connecticut recommends that your billing staff is aware of this requirement, and that your physicians and other practitioners and coders are collaborating to ensure complete and accurate documentation, code assignment and reporting of diagnoses and procedures. CarePartnersCT Standard 837 Companion Guide Reporting Options and Definitions N (No) Not present at the time of inpatient admission U (Unknown) Documentation is insufficient to determine if condition is present at time of inpatient admission W Not Applicable Y (Yes) Present at the time of inpatient admission The POA data element on your electronic claims has been moved from the K3 segment (version 4010A1) to the HI - PRINCIPAL DIAGNOSIS and HI - OTHER DIAGNOSIS INFORMATION segments. NOTE: The value of 1 has been removed in 5010. Example: Below is an example of acceptable coding on an electronic claim: HI BF:4821:::::::N HI BF:25000:::::::Y CarePartnersCT Standard 837 Companion Guide 9 TRADING PARTNER AGREEMENTS TRADING PARTNERS An EDI Trading Partner is defined as any CarePartners of Connecticut customer (provider, billing service, software vendor, employer group, financial institution, etc.) that transmits to, or receives electronic data from CarePartners of Connecticut. CarePartners of Connecticut utilizes the File Exchange Request Form to establish the Trading Partners agreement set-up forms to process electronic transactions. 10 TRANSACTION SPECIFIC INFORMATION This section describes how ASC X12 Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that CarePartners of Connecticut 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 sub-set of the IGs 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 CarePartners of Connecticut In addition to the row for each segment, one or more additional rows are used to describe CarePartners of Connecticut usage for composite and simple data elements and for any other information. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. CarePartnersCT Standard 837 Companion Guide These tables contain one or more rows for each segment for which a supplemental instruction is needed. Legend BOLDED and SHADED rows represent loops or segments in the X12N implementation guides. NON-SHADED rows represent data elements in the X12N implementation guides. 005010X223A2 Health Care Claim: Institutional Page Loop ID Reference Name Codes Length Notes Comments 1000A NM1 Information Source Name 72 1000A NM109 Submitter Identification Code 2 80 The existing trading partners will continue using the six-digit submitter code. CarePartners of Connecticut will work with new trading partners prior to implementation to determine the six-digit submitter code. (Exceptions to the six digit IDs may apply) 94 2010AB NM1 Pay-To Address Name N A This loop has been changed to indicate a separate address for payments to the Billing Provider. Please note that CarePartners of Connecticut will continue making payments to the address in our backend system database instead of the address submitted in 2010AB. 109 2000B SBR Subscriber Hierarchical Level 109 2000B SBR01 Payer Responsibility Sequence Number Code 1 1 This data element is NOT a payer counter. It is a code that indicates the order of responsibility for payment. 112 2010BA NM1 Subscriber Name N A 135 2010CA NM1 Patient Name N A As stated in Section 7: Each CarePartners of Connecticut member is uniquely identified by his or her member ID. All members should be considered as subscribers, and providers should submit member ID in Element NM109 of Loop 2010BA. CarePartners of Connecticut will not accept any data in the Patient Loop (2000C) and will REJECT accordingly. 166 2300 REF Payer Claim Control Number 166 2300 REF02 Reference Identification 1 50 For frequency types 5, 7, and 8, Original Reference Number (Claim Number) must be submitted as stated in the technical report. CarePartners of Connecticut also strongly recommends sending the Original Reference Number with frequency types 2, 3, and 4. CarePartnersCT Standard 837 Companion Guide Page Loop ID Reference Name Codes Length Notes Comments 271 2300 HI01-2 Occurrence Code 1 30 If a claim is accident or employment related, CarePartners of Connecticut requires the appropriate occurrence code. We will only process one iteration of HI01. 272 2300 HI01-4 Date Time Period 1 35 If a claim is accident or employment related, CarePartners of Connecticut requires the appropriate occurrence date. We will only process one iteration of HI01 341 2310E NM1 Service Facility Location Name N A CarePartners of Connecticut REQUIRES that Service Facility Information always matches Billing Provider Information given that the payee should always equal the provider on institutional claims. 354 2320 Other Subscriber Information N A 354 2320 SBR Other Subscriber Information N A Required by CarePartners of Connecticut to understand the payer responsibility sequence. 354 2320 AMT COB Payor Amount Paid N A CarePartners of Connecticut requires the total amount paid at the claim level 377 2330A NM1 Other Subscriber Name N A CarePartners of Connecticut requires this segment for COB claims. 384 2330B NM1 Other Payer Name N A CarePartners of Connecticut requires this segment for COB claims. 476 2430 SVD Line Adjudication Information N A 477 2430 SVD02 Monetary Amount 1 18 CarePartners of Connecticut requires the amount paid by the payer in 2330B for this line. 481 2430 CAS01 Claim Adjustment Group Code CO Contractual Obligations 1 2 Used to validate total amount billed in SV1 segment. 481 2430 CAS01 Claim Adjustment Group Code PR Patient Responsibility 1 2 Also used to validate total amount billed in SV1 segment. (if applicable) CarePartnersCT Standard 837 Companion Guide 005010X222A1 Health Care Claim: Professional Page Loop ID Reference Name Codes Length Notes Comments 75 1000A NM1 Submitter Name 75 1000A NM109 Submitter Identifier 2 80 The existing trading partners will continue using the six-digit submitter code. CarePartners of Connecticut will work with new trading partners prior to implementation to determine the six-digit submitter code. (Exceptions to the six digit IDs may apply) 83 2000A PRV Billing Provider Specialty Information N A CarePartners of Connecticut recommends providers include the appropriate taxonomy code for the services rendered. 83 2000A PRV01 Provider Code BI 1 3 Code identifying the type of provider 83 2000A PRV02 Code qualifying the Reference Identification PXC 2 3 Health Care Provider Taxonomy Code 83 2000A PRV03 Reference Identification 1 50 Provider Taxonomy Code 101 2010AB Pay-To Address Name N A This loop has been changed to indicate a separate address for payment to the Billing Provider. Please note that CarePartners of Connecticut will continue making payments to the address in our backend system database instead of the address submitted in 2010AB. 116 2000B SBR Subscriber Hierarchical Level 116 2000B SBR01 Payer Responsibility Sequence Number Code 1 1 This data element is NOT a payer counter. It is a code that indicates the order of responsibility for payment. 121 2010BA NM1 Subscriber Name N A 123 2010BA NM109 Identification Code 2 80 Each CarePartners of Connecticut member is uniquely identified by his or her member ID. Thus we require treating all members as subscribers, and submitting member ID in NM109 of loop 2010BA. 147 2010CA NM1 Patient Name N A As stated in section 7: Each CarePartners of Connecticut member is uniquely identified by his or her member ID. All members should be considered as subscribers, and providers should be submitting member ID in Element NM109 of Loop 2010BA. Thus CarePartners of Connecticut will not accept any data in the Patient Loop (2000C) and will REJECT accordingly. CarePartnersCT Standard 837 Companion Guide Page Loop ID Reference Name Codes Length Notes Comments 196 2300 REF Payer Claim Control Number N A 196 2300 REF02 Reference Identification 1 50 For frequency types 5, 7, and 8, Original Reference Number (Claim Number) must be submitted as stated in the technical report. CarePartners of Connecticut also strongly recommends sending Original Reference Number with frequency types 2, 3, and 4. 265 2310B PRV Rendering Provider Specialty Information CarePartners of Connecticut recommends providers include the appropriate taxonomy code for the services rendered. 265 2310B PRV01 Provider Code PE 1 3 Code identifying the type of provider 265 2310B PRV02 Code qualifying the Reference Identification PXC 2 3 Health Care Provider Taxonomy Code 265 2310B PRV03 Reference Identification 1 50 Provider Taxonomy Code 320 2330B NM1 Other Payer Name N A CarePartners of Connecticut requires this segment for COB claims. 480 2430 SVD Line Adjudication Information N A 481 2430 SVD02 Monetary Amount 1 18 CarePartners of Connecticut requires the amount paid by the payer in 2330B for this line. 485 2430 CAS01 Claim Adjustment Group Code CO Contractual Obligation 1 2 Used to validate total amount billed in SV1 segment. 485 2430 CAS01 Claim Adjustment Group Code PR Patient Responsibility 1 2 Also used to validate total amount billed in SV1 segment. (if applicable) CarePartnersCT Standard 837 Companion Guide APPENDICES A - EDI Set Up Form CarePartnersCT Standard 837 Companion Guide This form is also available on the CarePartners of Connecticut Public Provider website: https: www.carepartnersct.com cpct-pdoc-edi-set-up-form B - Transaction Examples 837 Institutional Claim Sample: ISA 00 00 ZZ Sender ID 33 16307 170424 0814 00501 006110829 1 P: GS HC Sender ID 16307 20170424 0814 6110829 X 005010X223A2 ST 837 0001 005010X223A2 BHT 0019 00 6110829N1 20170424 081458 CH NM1 41 2 ABC SYSTEMS INC 46 Sender ID PER IC CLAIMS CLEARINGHOUSE EM ABC Company abcc.com NM1 40 2 CAREPARTNERS OF CONNECTICUT 46 16307 HL 1 20 1 PRV BI PXC 282N00000X NM1 85 2 MEDICAL CENTER XX 1234567890 N3 3801 SPRING STREET N4 RACINE WI 534051667 REF EI 123456789 PER IC PATIENT ACCOUNTS TE 8885551212 NM1 87 2 N3 PO BOX 860004 N4 MINNEAPOLIS MN 554866000 HL 2 1 22 0 SBR P 18 CAREPARTNERS OF CONNECTICUT CI NM1 IL 1 DOE JANE MI 12345678901 N3 3400 10 AVE N4 RACINE WI 53402 DMG D8 19880227 F NM1 PR 2 CAREPARTNERS OF CONNECTICUT PI 16307 CLM 987654321 1109.2 13:A:1 A Y Y DTP 434 RD8 20170418-20170418 CL1 1 1 01 REF D9 6110829N1 REF EA E2675423 HI ABK:S8391XA HI APR:M25561 HI ABN:V484XXA HI BH:11:D8:20170418 NM1 71 1 SMITH MAMTA MALIK XX 1234567899 PRV AT PXC 207P00000X NM1 72 1 SMITH MAMTA MALIK XX 1234567899 LX 1 SV2 0250 1.2 UN 1 DTP 472 D8 20170418 REF 6R 34289381 LX 2 SV2 0320 HC:73564:RT 343 UN 1 DTP 472 D8 20170418 REF 6R 34289382 LX 3 SV2 0450 HC:99283 765 UN 1 DTP 472 D8 20170418 REF 6R 34289383 SE 47 0001 GE 1 6110829 IEA 1 006110829 CarePartnersCT Standard 837 Companion Guide 837 Professional Claim Sample: ISA 00 00 ZZ SENDERID 33 16307 170424 0253 00501 006110824 1 P: GS HC SENDERID 16307 20170424 0253 6110824 X 005010X222A1 ST 837 0001 005010X222A1 BHT 0019 00 6110824N1 20170424 025343 CH NM1 41 2 NEBO SYSTEMS INC 46 SENDERID PER IC CLAIMS CLEARINGHOUSE EM ABC Company abcc.com NM1 40 2 CAREPARTNERS OF CONNECTICUT 46 16307 HL 1 20 1 NM1 85 2 ABC HEALTH VENTURE XX 1234567896 N3 3471 EAGLE WAY N4 CHICAGO IL 606781034 REF EI 123456789 HL 2 1 22 0 SBR P 18 4886800 CI NM1 IL 1 DOE JANE MI 98765432101 N3 542 S KATHLEEN DR N4 ROMEOVILLE IL 60446 DMG D8 20040827 F NM1 PR 2 CAREPARTNERS OF CONNECTICUT PI 16307 CLM 123456789321 369 21:B:1 Y A Y Y DTP 431 D8 20170407 DTP 435 D8 20170407 DTP 096 D8 20170409 REF D9 6110824N1 REF EA GE12447281 HI ABK:T383X2A ABF:F322 ABF:T1491 NM1 DN 1 JONES JOE XX 1234567890 NM1 82 1 DOE SHYAMSUNDER XX 1234567891 PRV PE PXC 2084P0800X NM1 77 2 GOOD HOSPITAL IP XX 1234567893 N3 801 S WASHINGTON ST N4 NAPERVILLE IL 605407430 LX 1 SV1 HC:99253 369 UN 1 1:2:3 DTP 472 D8 20170408 REF 6R 454902631 SE 35 0001 GE 1 6110824 IEA 1 006110824 C - Change Summary This section describes the differences between the current Companion Guide and previous guide(s). Revision Revision Date Comments 1 10 2018 Version 5010 | /kaggle/input/edi-db-835-837/837-claims-transactions-guide.pdf | 27ed6d7a689e94c5ed4aced0003d5cdf | 27ed6d7a689e94c5ed4aced0003d5cdf_0 |
Page 1 of 13 Standard Companion Guide Refers to the Implementation Guide Based on X12 Version 005010X221A1 Health Care Claim Payment Advice (835) Companion Guide Version Number: 3.0 May 2024 Page 2 of 13 CHANGE LOG Version Release date Changes 1.0 08 08 2013 Initial External Release Draft 1.2 09 17 2014 PLB segment Notes 1.3 12 15 2016 Removed REF 1W other claim related identification for Member ID reporting 2.0 1 19 2018 Reformatted entire document and updated various sections with current information, including hyperlinks and contacts. 2.1 7 31 2018 Updated phone number for EDI Support and hyperlink to EDI Transaction Support form 3.0 5 22 2024 Updated logo and PLB segment Notes, Claim Filing Indicator codes, and Payment Method Codes. Page 3 of 13 PREFACE This Companion Guide to the ASC X12N 005010X221A1 Health Care Claim Payment Advice (835) Implementation Guide, also known as Technical Report Type 3 (TR3), clarifies and specifies the data content when exchanging electronically with UnitedHealth care. Transmissions based on this companion guide, used in tandem with the specified ASC X12 005010X221A1 835 Implementation 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 005010X221A1 835 implementation Guide adopted for use under HIPAA (Health Insurance Portability and Accountability Act). The Companion Guide is not intended to convey information that exceeds the requirements or usages of data expressed in the Implementation Guides. Page 4 of 13 Table of Contents CHANGE LOG...........................................................................................................................2 PREFACE.................................................................................................................................3 1. INTRODUCTION..............................................................................................................5 1.1. SCOPE...........................................................................................................................6 1.2. OVERVIEW....................................................................................................................6 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 3. CONNECTIVITY WITH THE PAYER COMMUNICATIONS......................................................7 3.1. PROCESS FLOW..............................................................................................................7 3.2. RE-TRANSMISSION PROCEDURE.......................................................................................8 5.1. ISA-IEA..........................................................................................................................8 5.2. GS-GE...........................................................................................................................9 5.3. ST-SE............................................................................................................................9 6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS..........................................................9 6.1. 835 ENROLLMENTS.........................................................................................................9 7. ACKNOWLEDGEMENTS AND OR REPORTS.........................................................................9 7.1. REPORT INVENTORY.......................................................................................................9 8. TRADING PARTNER AGREEMENTS....................................................................................9 8.1. TRADING PARTNERS.......................................................................................................9 9. TRANSACTION SPECIFIC INFORMATION.......................................................................... 10 10. APPENDECIES........................................................................................................ 12 10.1. IMPLEMENTATION CHECKLIST................................................................................. 12 10.2. FREQUENTLY ASKED QUESTIONS............................................................................. 12 10.3. UNITEDHEALTHCARE COMMUNITY PLAN PAYER IDs.................................................. 13 Page 5 of 13 1. INTRODUCTION This section describes how Technical Report Type 3 (TR3), also called Health Care Claim: Professional (835) 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 something additional, over, and above, the information in the TR3. 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 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: IG Page Loop Reference Name Codes Length Comments 71 1000A NM1 Submitter Name This type of row 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 Page 6 of 13 114 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 only valid value. 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 This row illustrates how to indicate a component data element in the Reference column and how to specify that only one code value is applicable 1.1. SCOPE This guide is to be used by the Trading Partner for the development of the ASC X12 005010X221A1 835 transaction for the purpose of reporting claim payment information from UnitedHealthcare. 1.2. OVERVIEW This UnitedHealthcare Community Plan Health Care Claim Payment Advice Companion Guide has been written to assist you in designing and implementing Claim Payment Advice transactions to meet UnitedHealthcare's processing standards. This Companion Guide must be used in conjunction with the Health Care Claim Payment Advice (835) instructions as set forth by the ASC X12 Standards for Electronic Data Interchange (Version 005010X221), April 2006, and the Errata (Version 005010X221A1), June 2010. The UnitedHealthcare Companion Guide identifies key data elements from the transaction set that will be provided in the transaction. The recommendations made are to enable you to more effectively complete EDI transactions with UnitedHealthcare. 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. Page 7 of 13 1.3. REFERENCE For more information regarding the ASC Standards for Electronic Data Interchange (X12 005010X221A1) Health Care Claim Payment Advice (835) 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 Version 005010X222A1, we have compiled the UnitedHealthcare specific CG. We are not responsible for any changes and updates made to the IG. 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, Optum360, 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 ASC X12N 005010X221A1 Health Care Claim Payment Advice transaction (835), as well as associated timeframes, costs, etc. This includes protocols for testing the exchange of transactions with UnitedHealthcare through your clearinghouse. To receive Electronic Funds Transfer, you should enroll in Electronic Payments and Statements online. If questions, contact EDI Support by: Using our EDI Transaction Support Form Sending an email to ac_edi_ops uhc.com Calling 800-210-8315 3. CONNECTIVITY WITH THE PAYER COMMUNICATIONS 3.1. PROCESS FLOW Page 8 of 13 835 Connection File Delivery Flows Clearinghouse Connectivity 3.2. RE-TRANSMISSION PROCEDURE 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 ac_edi_ops uhc.com or calling 800-842- 1109. The 835 files 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 files from to discuss how to receive a re-transmission. 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. For assistance with understanding your 835 or for more information on our direct connection, please contact EDI Support by using our EDI Transaction Support Form, sending an email to ac_edi_ops uhc.com or calling 800-210-8315. If you have questions related to submitting transactions through a clearinghouse, please contact your clearinghouse or software vendor directly. 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 files: UnitedHealthcare uses the following delimiters on your 835 files: Community Plan 835 Optum360 Connectivity Solutions Provider is Trading Partner? Clearinghouse, VAN, etc. YES Page 9 of 13 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. 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. 7. ACKNOWLEDGEMENTS AND OR REPORTS Currently UnitedHealthcare does not provide acknowledgments or reporting on the 835 transactions. 7.1. REPORT INVENTORY No 835 reporting inventory is available currently. 8. TRADING PARTNER AGREEMENTS 8.1. TRADING PARTNERS An EDI Trading Partner is defined as any UnitedHealthcare customer (provider, billing service, software vendor, employer group, financial institution, etc.) that transmits to, or receives Page 10 of 13 electronic data directly from UnitedHealthcare. 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. The agreement is related to the electronic exchange of information. The agreement is an entity or a part of a larger agreement, between each party to the agreement. The Trading Partner Agreement may specify among other things, the roles, and responsibilities of each party to the agreement in conducting standard transactions. Since your clearinghouse is considered the EDI Trading Partner, you are covered under a larger agreement and there is no need to execute an EDI Trading Partner Agreement with UnitedHealthcare Community Plan. 9. TRANSACTION SPECIFIC INFORMATION UnitedHealthcare has put together the following grid to assist you in designing and programming the information we would provide 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 IG. 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 internal code listings 4. Clarify the use of loops, segments, composite, and simple data elements 5. Provide 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. The following table describes UnitedHealthcare Services Company of the River Valley, Inc. (UnitedHealthcare) selections within the context of the HIPAA Implementation Guides and Addenda. Page 11 of 13 LEGEND: Shaded rows represent segments in the X12N Implementation Guide. NON-SHADED rows represent data elements in the X12N Implementation Guide. IG Page Loop Reference Name Codes Length Comments 69 BPR Financial Information 70-71 BPR01 Transaction Handling Code C, I UHC will use C (Payment Accompanies Remit) or I (remittance Info Only). 71 BPR03 Credit Debit Flag Code C UHC will use C (Credit). 72 BPR04 Payment Method Code ACH, CHK, NON, UHC will use ACH (Automated Clearinghouse), CHK (Check), BOP, or NON (Non-Payment Data). 72 BPR05 Payment Format Code CTX UHC will use CCP (Corporate Trade Exchange) 112 2000 TS3 Provider Summary Information 113 2000 TS301 Reference Identification The Provider tax ID plus a two- character identification number assigned by UHC under which the claims was judged. 123 2100 CLP Claim Payment Information Claim Payment Information 124 2100 CLP02 Claim Status Code 1, 2, 19, 22 UHC will use the following values for the claim status codes: 1- Processed as Primary, 2- Processed as Secondary, 19-Processed as Primary, forwarded to additional payers, 22- Reversal of Previous Payment 126- 127 2100 CLP06 Claim Filing Indicator Code HM, MC 12, or 13 UHC will return the appropriate qualifier that aligns with the insurance plan adjudicated 140 2100 NM1 Patient Name 142 2100 NM108 Identification Code Qualifier MI Member Identification Qualifier 142 2100 NM109 Identification Code Qualifier Member Identification code as submitted on the inbound claim 146 2100 NM1 Service Provider Name 148 2100 NM108 Identification Code Qualifier XX UHC (UnitedHealthcare) will use XX (National Provider Identifier) Page 12 of 13 149 2100 NM109 Identification Code UHC Unique Provider ID The provider tax ID plus a two- character identification number assigned by UHC under which the claim was adjudicated. 182 2100 AMT Claim Supplemental Information 182- 183 2100 AMT01 Amount Qualifier Code AU UHC will use AU (Coverage Amt) to report the total net allowed amount for the claim 186 2110 SVC Service Payment Information UHC will report service lines for professional, dental, and outpatient institutional services. Service line detail for inpatient institutional claims is not provided. 206 2110 REF Line-Item Control Number 206 2110 REF01 Reference Identification Qualifier 6R UHC will return the Patient Control Number from the inbound 837 2400 loop REF02 if supplied 211 2110 AMT Service Supplemental Amount 211- 212 2110 AMT01 Amount Qualifier Code B6 UHC will report B6 (Allowed - Actual Amount) to indicate the total net amount allowed for service lines. 217 PLB Provider Adjustment 219- 222 PLB03-1 Adjustment Reason Code FB, L3, L6 and WO UHC will use: FB qualifier for the Forward Balance (negative amount) that will be recovered from a provider's future remits. The Reference ID will includes Patient Acct number, Claim number, and remit number, WO qualifier for the overpayment recovery, along with the members account number. 10. APPENDECIES 10.1.IMPLEMENTATION CHECKLIST 1. Contact your Clearinghouse to enroll in Electronic Funds Transfer (EFT) 2. Enroll in Electronic Payments and Statements (EPS) with UnitedHealthcare Optum 10.2.FREQUENTLY ASKED QUESTIONS 1. Does this companion guide apply to all UnitedHealthcare Payers? No. This companion guide will apply to UnitedHealthcare Community and State Plans. 2. Why are the claim adjustment reason codes different than the adjustment codes on the EOB? Page 13 of 13 The adjustment codes reported in the 835 transactions are from the National Claim Adjustment Reason Code list. In most instances the UnitedHealthcare proprietary adjustment codes are reported on the EOB. 3. If a claim is submitted to UnitedHealthcare on paper and not in an 837 will the claim payment data be reported in the 835? Yes, the source of claim submission does not impact the 835 reporting. 4. If a claim is closed for additional information will the closed claim be reported in the 835? No. UnitedHealthcare only reports claims that are paid or denied are reported in the 835. 5. Does enrollment to receive the 835 transaction impact the payment cycle? No, the generation of the 835 transaction will mirror the current payment cycle for the physician or health care professional. 10.3.UNITEDHEALTHCARE COMMUNITY PLAN PAYER IDs For a complete listing of claims and electronic remittance advice (ERA) Payer IDs for UnitedHealthcare Community Plan payers, refer to our Claims payer list and ERA payer List, both posted online at UHCprovider.com EDI. | /kaggle/input/edi-db-835-837/EDI-835-Companion-Guide-UHCCP-005010X221A1.pdf | dd104f6071fcaa69ef82dac993fcddb0 | dd104f6071fcaa69ef82dac993fcddb0_0 |
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