MINNESOTA HEALTH CARE PROGRAMS Professional, Institutional, and Dental Claims

Transcription

Minnesota Department of Human Services
MINNESOTA HEALTH CARE PROGRAMS
837 Encounter Companion Guide to the HIPAA Implementation Guide
Professional, Institutional, and Dental Claims
FINAL Revision Date: 12/16/2013 - FINAL
See Change Control page for Implementation Dates of Data Elements
EDI Mapping Specifications - Introduction
Page 2 of 77
CHANGE CONTROL
Date Revised
09/19/2013
Revised By
D.Preciado
09/19/2013
D. Preciado
09/25/2013
D. Preciado
11/04/2013
D. Preciado
11/25/2013
D. Preciado
Revisions
Red additions identify changes for TPL data
capture (HMS implementation)
Yellow highlighted red additions identify corrections
to 837 Encounter Companion Guide
Aqua highlighted additions identify fields for
MCO PAID DATE in 837D
Pink highlighted additions identify changes for
Service Facility & Taxonomy Code
Added DTP segment to Loop 2330B of 837D,
837I and 837P transactions. (HMS
implementation)
Implementation Date
03/01/2014
12/01/2013
01/01/2014
07/01/2014
03/01/2014
2
Contents
1
INTRODUCTION ......................................................................................................................................................................................................... 4
2
PROFESSIONAL ........................................................................................................................................................................................................ 5
ENVELOPE INFORMATION ....................................................................................................................................................................................... 25
3
INSTITUTIONAL ....................................................................................................................................................................................................... 27
4
DENTAL .................................................................................................................................................................................................................. 55
APPENDIX – PAID AMOUNT AND ALLOWED AMOUNT RULES ............................................................................................................................ 77
3
1 INTRODUCTION
1.1 Document Purpose
Managed Care Organizations (MCOs) contracting with the Minnesota Department of Human Services (DHS) to provide
prepaid health care services are required to provide encounter data in HIPAA compliant format. This companion guide
further specifies the requirements to be used when preparing and submitting encounter data.
Disclaimer
The companion guide supplements, but does not contradict, disagree, oppose, or otherwise modify the HIPAA
Implementation Guide in a manner that will make its implementation by users to be out of compliance.
1.2 Column Notations
Req’d: Required elements may be marked as:
• Required (Y)
• Not required (N)
• Conditional according to the 837 HIPAA implementation guide (C1)
• Conditional according to DHS additional requirements (C2)
Value: If a value is present in the DHS Requirements Value Column the values MUST be entered. If no value is present
refer to the Descriptions column for instructions.
Description Column: This column will describe the value in the value column or give instructions for what must be
submitted in the value column.
4
2 PROFESSIONAL
837P HIPAA Implementation Guide Data
LOOP
SEGMENT
HDR
ST
NAME
ID
HEADER
TRANSACTION SET HEADER
ST01
ST02
BHT
1000A
ELEMENT NAME
TRANSACTION SET IDENTIFIER
CODE
TRANSACTION SET CONTROL
NUMBER
ST03
IMPLEMENTATION
CONVENTION REFERENCE
BHT01
HIERARCHICAL STRUCTURE
CODE
BHT02
BHT03
BHT04
BHT05
BHT06
DHS Encounter Data
REQ
VALUE(S)
DHS REQUIREMENT DESCRIPTION
Y
Y
837
HEALTH CARE CLAIM
Y
005010X222
A1
MUST BE SAME AS GS08
Y
Y
0019
INFORMATION SOURCE, SUBSCRIBER,
DEPENDENT
TRANSACTION SET PURPOSE
CODE
Y
00
ORIGINAL
18
REFERENCE IDENTIFICATION
DATE
TIME
TRANSACTION TYPE CODE
Y
Y
Y
Y
REISSUE
SUBMISSION NUMBER-MCO ASSIGNED
TRANSACTION SET CREATION DATE
TRANSACTION SET CREATION TIME
REPORTING
THIS LOOP IS USED FOR INFORMATION
REGARDING THE MCO RESPONSIBLE
FOR THE ENCOUNTER.
BEGIN OF HIERARCHICAL TXN
Y
MCO SYSTEM GENERATED NUMBER
RP
SUBMITTER NAME
NM1
SUBMITTER NAME
Y
NM101
ENTITY IDENTIFIER CODE
Y
41
NM102
ENTITY TYPE QUALIFIER
Y
2
NM103
Y
NM109
NAME LAST OR ORGANIZATION
NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
PER01
CONTACT FUNCTION CODE
Y
PER02
NAME
Y
NM108
PER
SUBMITTER EDI CONTACT
INFO
Y
VALUE 41 SHOULD BE SUBMITTED EVEN
THOUGH THIS IS MCO INFORMATION.
NON-PERSON ENTITY
MCO NAME (OR CONTRACTOR NAME)
46
Y
Y
TRADING PARTNER ID
MCO UMPI NUMBER ASSIGNED BY DHS
IC
INFORMATION CONTACT
MCO SUBMITTER CONTACT
5
LOOP
SEGMENT
NAME
ID
PER03
PER04
1000B
NM1
HL
PRV
NM1
COMMUNICATION NUMBER
QUALIFIER
Y
TE
TELEPHONE
NM109
HL01
HL03
HL04
HIERARCHICAL ID NUMBER
HIERARCHICAL LEVEL CODE
HIERARCHICAL CHILD CODE
BILLING/PAY-TO PROVIDER
HIERARCHICAL LEVEL
HIERARCHICAL LEVEL
BILLING PROVIDER
SPECIALTY INFORMATION
MCO CONTACT PHONE NUMBER
40
2
RECEIVER
NON-PERSON ENTITY
MN DEPT OF HUMAN SERVICES
Y
46
TRADING PARTNER ID
Y
Y
411674742
RECEIVER ID
Y
Y
Y
Y
PRV03
PROVIDER CODE
QUALIFIER
NM101
Y
Y
Y
Y
NM102
Y
NM103
NAME
Y
NM104
NM108
NAME FIRST
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
C1
C1
BILLING PROVIDER NAME
NM109
Y
Y
Y
Y
Y
Y
20
1
1 THEN INCREMENT BY 1
INFORMATION SOURCE
ADDITIONAL SUBORDINATE HL DATA
SEGMENT IN THIS HIERARCHICAL
STRUCTURE
C1
PRV01
PRV02
2010AA
VALUE(S)
ENTITY IDENTIFICAT CODE
NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
NM108
2000A
REQ
RECEIVER NAME
RECEIVER NAME
NM101
NM102
NM103
DHS Encounter Data
ELEMENT NAME
Y
Y
BI
PXC
BILLING
HEALTH CARE PROVIDER TAXONOMY
CODE
PROVIDER TAXONOMY CODE
85
BILLING PROVIDER
Correction of QUALIFIER DESCRIPTION
based on review of X12 implementation
guide.
PAY TO PROVIDER
PERSON
NON-PERSON ENTITY
DEFAULT TO ANY TEXT-NOT USED BUT
REQUIRED BY STANDARD BILLING
PROVIDER LAST OR ORGANIZATIONAL
NAME
BILLING PROVIDER FIRST NAME
NPI
C1
1
2
XX
BILLING PAY TO PROVIDER-NPI
6
LOOP
SEGMENT
N3
N4
REF
2000B
HL
SBR
NAME
ID
REQ
N301
ADDRESS INFORMATION
Y
Y
N302
ADDRESS INFORMATION
C1
Y
N401
CITY NAME
Y
N402
STATE OR PROVINCE CODE
N403
POSTAL CODE
REF01
QUALIFIER
C1
Y
C1
Y
Y
C1
Y
REF02
BILLING PROVIDER TAX
IDENTIFICATION NUMBER
BILLING PROVIDER ADDRESS
BILLING PROVIDER
CITY/STATE/ZIP
IDENTIFICATION
SUBSCRIBER HIERARCHICAL
LEVEL
HIERARCHICAL LEVEL
VALUE(S)
DEFAULT TO ANY TEXT NOT USED BUT
PROVIDER ADDRESS LINE
BILLING PROVIDER ADDRESS LINE
“ANY TEXT” BILLING PROVIDER CITY
NAME
MN BILLING PROVIDER STATE OR
PROVINCE CODE
ANY ZIP CODE BILLING PROVIDER
POSTAL ZONE OR ZIP CODE (9 DIGIT)
EI
Y
PROVIDERS EMPLOYER
PROVIDERS EMPLOYERS
IDENTIFICATION NUMBER OR DEFAULT
TO ANY NUMBER NEEDED FOR
STANDARD
Y
HL01
Y
Y
HL02
HIERARCHICAL PARENT ID
Y
HL03
HL04
Y
Y
22
0
SBR01
PAYER RESPONSIBILITY
SEQUENCE NUMBER CODE
Y
Y
P
PRIMARY
S
T
18
SECONDARY
TERTIARY
SELF
MC
MEDICAID
SUBSCRIBER INFORMATION
SBR02
SBR09
DHS Encounter Data
ELEMENT NAME
INDIVIDUAL RELATIONSHIP
CODE
CLAIM FILING INDICATOR CODE
C1
Y
C1
Y
START WITH 2 AND INCREMENT BY 1.
1 FOR FIRST ITERATION. CHANGES TO
PROVIDER HL01 VALUE WHEN
PROVIDER NUMBER CHANGES IN A
TRANSACTION SET.
SUBSCRIBER
NO SUBORDINATE HL SEGMENT IN THIS
7
LOOP
SEGMENT
2010BA
NM1
NAME
ID
REQ
VALUE(S)
NM101
Y
Y
Y
IL
INSURED OR SUBSCRIBER
NM102
NM103
NAME
NAME FIRST
1
PERSON
SUBSCRIBER LAST NAME
SUBSCRIBER NAME
SUBSCRIBER NAME
NM104
NM105
NM108
N3
N4
DMG
NM109
NAME MIDDLE
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
N301
ADDRESS INFORMATION
SUBSCRIBER ADDRESS
SUBSCRIBER CITY/STATE/ZIP
N402
N403
POSTAL CODE
DMG01
DATE TIME PERIOD FORMAT
QUALIFIER
DATE TIME PERIOD
GENDER CODE
C2
Y
C2
Y
C2
Y
Y
PROPERTY AND CASUALTY
CLAIM NUMBER
MI
Y
Y
SUBSCRIBER MIDDLE INITIAL, IF KNOWN
MEMBER IDENTIFICATION NUMBER
DHS ASSIGNED EIGHT DIGIT MEMBER ID
SINCE THE PATIENT IS ALWAYS THE
SUBSCRIBER UNDER MHCP, THIS
SEGMENT IS REQUIRED.
DEFAULT TO ANY TEXT – NOT USED
BUT REQUIRED BY STANDARD.
BUT REQUIRED BY STANDARD
DEFAULT TO “00000”.
Y
Y
D8
U
F
M
DATE EXPRESSED IN FORMAT
CCYYMMDD
SUBSCRIBER BIRTH DATE
UNKNOWN (DEFAULT)
FEMALE
MALE
Y4
AGENCY CLAIM NUMBER
C2
REF02
NM1
SUBSCRIBER FIRST NAME
Y
C2
CITY NAME
SUBSCRIBER DEMOGRAPHICS
PAYER NAME
PAYER NAME
C2
Y
C1
Y
N401
REF01
2010BB
Y
Y
C2
DMG02
DMG03
REF
DHS Encounter Data
ELEMENT NAME
QUALIFIER
Y
Y
Y
Y
MCO’S OWN MEMBER ID
8
LOOP
SEGMENT
NAME
ID
REQ
VALUE(S)
NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
Y
Y
Y
PR
2
PAYER
NON-PERSON ENTITY
Y
PI
PAYER ID
Y
C1
411674742
DHS PAYER ID
REF01
QUALIFIER
Y
G2
REF02
Y
Y
(REPLACES 2010AA PAY TO PROVIDER
UMPI)
PROVIDER COMMERCIAL NUMBER
UMPI OF BILLING PAY TO PROVIDER
CLM01
CLAIM SUBMITTER’S IDENTIFIER
Y
MCO’S OWN CLAIM NUMBER (ICN)
CLM02
MONETARY AMOUNT
Y
TOTAL CLAIM CHARGE AMOUNT (BILLED
AMOUNT) PER APPENDIX A IN THE
IMPLEMENTATION GUIDE, DECIMAL
DATA ELEMENTS IN DATA ELEMENT 782
WILL BE LIMITED TO A MAXIMUM
LENGTH OF 10 CHARACTERS
INCLUDING REPORTED OR IMPLIED
PLACES FOR CENTS.
CLM05
HEALTH CARE SERVICE
LOCATION INFORMATION
FACILITY CODE VALUE
Y
FACILITY CODE QUALIFIER
Y
B
CLAIM FREQUENCY TYPE CODE
(CLAIM SUBMISSION REASON
CODE)
Y
1
PLACE OF SERVICE CODE FOR
PROFESSIONAL OR DENTAL SERVICES
ORIGINAL
Y
7
8
Y
REPLACEMENT
VOID
YES (DEFAULT)
N
NO
NM101
NM102
NM103
NM108
NM109
REF
2300
CLM
BILLING PROVIDER
SECONDARY IDENTIFICATION
CLAIM INFORMATION
CLAIM INFORMATION
CLM051
CLM052
CLM053
CLM06
DHS Encounter Data
ELEMENT NAME
YES/NO CONDITION OR
RESPONSE CODE (PROVIDER
SIGNATURE ON FILE)
Y
PLACE OF SERVICE CODE
9
LOOP
SEGMENT
NAME
ID
CLM07
CLM08
DHS Encounter Data
ELEMENT NAME
REQ
VALUE(S)
PROVIDER ACCEPT
ASSIGNMENT CODE (MEDICARE
ASSIGNMENT CODE)
Y
A
ASSIGNED (DEFAULT)
B
ASSIGNMENT ACCEPTED FOR CLINICAL
LAB SERVICES ONLY
NOT ASSIGNED
YES (DEFAULT)
YES/NO CONDITION OR
RESPONSE CODE
(ASSIGNMENT OF BENEFITS
INDICATOR)
Y
C
Y
N
W
CLM09
RELEASE OF INFORMATION
CODE
Y
Y
I
CLM10
CLM11
CLM111 THRU
CLM113
DTP
ONSET OF CURRENT ILLNESS
PATIENT SIGNATURE SOURCE
CODE
RELATED CAUSES
INFORMATION
RELATED CAUSES CODE
NO
PATIENT REFUSES TO ASSIGN
BENEFITS
YES, PROVIDER HAS A SIGNED
STATEMENT PERMITTING RELEASE OF
MEDICAL BILLING DATA RELATED TO A
CLAIM (DEFAULT)
INFORMED CONSENT TO RELEASE
MEDICAL INFORMATION FOR
CONDITIONS OR DIAGNOSES
REGULATED BY FEDERAL STATUTES
C1
P
SIGNATURE GENERATED BY PROVIDER
IF THE PATIENT WAS NOT PHYSICALLY
PRESENT FOR SERVICES
AA
AUTO ACCIDENT
EM
OA
EMPLOYMENT
OTHER ACCIDENT
REQUIRED IF CLM11-1, -2 or -3 = AA TO
IDENTIFY THE STATE IN WHICH THE
AUTOMOBILE ACCIDENT OCCURRED.
USE THE STATE POSTAL CODE.
REQUIRED IF THE AUTOMOBILE
ACCIDENT OCCURRED OUT OF THE
UNITED STATES.
C1
Y
CLM114
C1
CLM115
COUNTRY CODE
C1
C1
10
LOOP
SEGMENT
DTP
AMT
REF
NAME
ID
REQ
VALUE(S)
DTP01
DATE/TIME QUALIFIER
Y
431
ONSET OF CURRENT ILLNESS
DTP02
Y
D8
DATE EXPRESSED IN CCYYMMDD
DTP03
QUALIFIER
DATE TIME PERIOD
DTP01
DATE/TIME QUALIFIER
DTP02
ACCIDENT DATE
ACCIDENT
Y
D8
DTP03
QUALIFIER
DATE TIME PERIOD
AMT01
AMOUNT QUALIFIER CODE
Y
AMT02
MONETARY AMOUNT
Y
ORIGINAL REFERENCE
NUMBER (ICN/DCN)
ONSET OF CURRENT ILLNESS DATE IN
CCYYMMDD FORMAT.
439
PATIENT AMOUNT PAID
FILE INFORMATION
Y
C1
Y
Y
C1
ACCIDENT DATE
ALL TPL AND/OR MEDICARE PAYMENT
INFORMATION IS SENT IN THIS
SEGMENT WHETHER THE PAYMENT IS
FROM THE PATIENT OR THE PROVIDER.
F5
PATIENT AMOUNT PAID. ENTER IF
APPLICABLE.
ENTER TOTAL TPL AND OR MEDICARE
PAYMENT HERE, IF APPLICABLE. PER
APPENDIX A IN THE IMPLEMENTATION
GUIDE, DECIMAL DATA ELEMENTS IN
DATA ELEMENT 782 WILL BE LIMITED TO
A MAXIMUM LENGTH OF 10
CHARACTERS INCLUDING REPORTED
OR IMPLIED PLACES FOR CENTS.
C1
REF01
K3
DHS Encounter Data
ELEMENT NAME
REF02
PAYER CLAIM CONTROL
NUMBER
K3
K301
FIXED FORMAT INFORMATION
Y
Y
C1
Y
F8
ORIGINAL REFERENCE NUMBER
MCO’S ORIGINAL CLAIM (ICN) NUMBER.
USED WHEN CLM05-3 IS 7REPLACEMENT OR 8-VOID. THIS IS FOR
REPLACEMENT CLAIM OR VOID CLAIM
USAGE ONLY.
FOR STATE OF JURISDICTION AND
TOOTH NUMBER/ORAL CAVITY.
11
LOOP
SEGMENT
CRC
NAME
ID
EPSDT REFERRAL
CRC
ELEMENT NAME
DHS Encounter Data
REQ
VALUE(S)
THIS SEGMENT IS SENT FOR CHILD AND
TEEN CHECKUP CLAIMS.
MUTUALLY DEFINED. EPSDT SCREEN
REFERRAL INFORMATION.
NO
C1
CRC01
CODE CATEGORY
Y
ZZ
CRC02
YES/NO CONDITION OR
RESPONSE CODE (WAS AN
EPSDT REFERRAL GIVEN TO
THE PATIENT?)
Y
N
CRC03
CONDITION INDICATOR
Y
Y
AV
NU
S2
ST
HI
HEALTH CARE INFORMATION
CODES
HI01
HEALTH CARE CODE
INFORMATION
CODE LIST QUALIFIER CODE
Y
HI01-2
HI102
THRU
HI12
HI02-1
THRU
HI12-1
INDUSTRY CODE
HEALTH CARE CODE
INFORMATION
Y
C1
CODE LIST QUALIFIER CODE(S)
Y
HI02-2
THRU
HI12-2
HI01
THRU
HI12
INDUSTRY CODE
Y
ICD-10-CM DIAGNOSIS CODE
DIAGNOSIS CODE
HEALTH CARE CODE
INFORMATION
C1
CONDITION CODE
HI01-1
Y
BK
ABK
BF
ABF
HI
CODES
YES
AVAILABLE NOT USED. PATIENT
REFUSED REFERRAL.
NOT USED. THIS CONDITION
INDICATOR MUST BE USED WHEN THE
SUBMITTER ANSWERS “N” IN CRC02.
UNDER TREATMENT-PATIENT IS
CURRENTLY UNDER TREATMENT FOR
REFERRED DIAGNOSTIC OR
CORRECTIVE HEALTH PROBLEM.
NEW SERVICES REQUESTED.
REFERRAL TO ANOTHER PROVIDER
FOR DIAGNOSTIC OR CORRECTIVE
TREATMENT/SCHEDULED FOR
ANOTHER APPOINTMENT WITH
SCREENING PROVIDER.
DO NOT SEND DECIMAL POINTS IN THE
DIAGNOSIS CODE.
ICD-9-CM PRINCIPAL DIAGNOSIS
PRINCIPAL DIAGNOSIS CODE
Added line based on review of X12
implementation guide. Only H101 is required
when this HI segment is used.
12
LOOP
SEGMENT
NAME
ID
HI01-1
THRU
HI12-1
HI01-2
THRU
HI01-2
2310A
NM1
REF
REQ
VALUE(S)
Y
BG
CONDITION
INDUSTRY CODE
Y
REFERRING PROVIDER NAME
INDIVIDUAL /ORG. NAME
NAME
NM104
NAME FIRST
C1
NM108
IDENTIFICATION CODE
QUALIFIER
Y
NM109
IDENTIFICATION CODE
Y
REFERRING PROVIDER
DN
1
XX
REFERRING PROVIDER
PERSON
DEFAULT TO ANY TEXT- REQUIRED IF
“1” IS SENT IN NM102.
NPI
REFERRING PROVIDER NPI
REF02
QUALIFIER
NM101
Y
Y
82
RENDERING PROVIDER
NM102
Y
1
PERSON
2
NM103
NAME
NAME FIRST
Y
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
C1
NON-PERSON
DEFAULT TO ANY TEXT- NOT USED BUT
REQUIRED BY STANDARD
NPI
INDIVIDUAL /ORG. NAME
NM104
NM108
NM109
CONDITION CODE
C1
RENDERING PROVIDER NAME
NM1
C1
Y
Y
Y
Y
NM101
NM102
NM103
REF01
2310B
DHS Encounter Data
ELEMENT NAME
Y
G2
PROVIDER COMMERCIAL NUMBER (FOR
UMPI NUMBERS)
DHS UMPI NUMBER.
REQUIRED WHEN RENDERING
PROVIDER INFORMATION IS DIFFERENT
THAN PROVIDER LISTED IN LOOP
2010AA
Y
C2
C1
C1
XX
RENDERING PROVIDER NPI NUMBER
13
LOOP
SEGMENT
REF
NAME
ID
RENDERING PROVIDER
REF02
NM1
C1
NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
SERVICE FACILITY LOCATION
ADDRESS
G2
UMPI NUMBERS)
DHS UMPI NUMBER.
REQUIRED WHEN THE LOCATION OF
HEALTH CARE SERVICE IS DIFFERENT
THAN THAT CARRIED IN LOOP 2010AA
Y
Y
Y
77
2
SERVICE LOCATION
NON-PERSON ENTITY
LABORATORY OR FACILITY NAME
C1
XX
NPI
C1
LABORATORY OR FACILITY PRIMARY
IDENTIFIER
Y
N301
ADDRESS INFORMATION
Y
N302
ADDRESS INFORMATION
C1
Y
N401
N402
CITY NAME
Y
C1
N403
POSTAL CODE
C1
CITY, STATE, ZIP CODE
LABORATORY OR FACILITY ADDRESS
LINE
LABORATORY OR FACILITY CITY NAME
LABORATORY OR FACILITY STATE OR
PROVINCE CODE
LABORATORY OR FACILITY POSTAL
ZONE OR ZIP CODE
C1
REF01
REF02
VALUE(S)
Y
NAME
NM109
REF
Y
C1
NM108
N4
QUALIFIER
NAME
NM101
NM102
NM103
N3
DHS Encounter Data
REQ
C2
REF01
2310C
ELEMENT NAME
QUALIFIER
Y
Y
G2
UMPI NUMBERS)
LABORATORY OR FACILITY
SECONDARY IDENTIFIER (DHS UMPI
NUMBER)
14
LOOP
SEGMENT
2320
SBR
NAME
ID
ELEMENT NAME
DHS Encounter Data
REQ
OTHER SUBSCRIBER
INFORMATION
C2
OTHER SUBSCRIBER
INFORMATION
Y
SBR01
SBR02
CODE
VALUE(S)
THIS LOOP IS REQUIRED ONLY WHEN
THERE ARE PHYSICIAN ADMINISTERED
DRUGS AND THIRD PARTY LIABILITY ON
THE CLAIM. IT IS REQUIRED SO THAT
LINE LEVEL TPL CAN BE SUBMITTED
FOR THE DRUGS. THIS LOOP IS
REQUIRED – THE FIRST OCCURRENCE
MUST CONTAIN INFORMATION FOR THE
MCO AS THE PRIMARY/SECONDARY
PAYER. IF THE PRIMARY PAYER IS A
THIRD PARTY, THE SECOND
OCCURRENCE OF THIS SEGMENT
SHOULD CONTAIN A “P” AND
INFORMATION RELATED TO THE
RELEVANT THIRD PARTY PAYER. UP
TO 10 SBR LOOPS CAN BE SENT.
Y
P
PRIMARY
SECONDARY
TERTIARY
REFER TO THE IMPLEMENTATION
GUIDE FOR THE OTHER CODES/VALUES
TO USE.
Y
S
T
SEE X12 IG
FOR
ADDT’L
CODES/
VALUES
18
SEE X12 IG
FOR
ADDT’L
CODES/
VALUES
SBR03
C1
SBR05
INSURANCE TYPE CODE
C1
SEE X12 IG
FOR
CODES/
VALUES
SELF– this is the only option for the first
occurrence. Subsequent occurrences should
be billed as appropriate.
TO USE.
INSURANCE GROUP OR POLICY
NUMBER
REQUIRED WHEN MEDICARE PRESENT
AND MEDICARE IS NOT PRIMARY
PAYER. REFER TO THE
IMPLEMENTATION GUIDE FOR THE
CODES/VALUES TO USE.
15
LOOP
SEGMENT
NAME
ID
SBR09
DHS Encounter Data
ELEMENT NAME
REQ
VALUE(S)
CLAIM FILING INDICATOR CODE
Y
HM
11
HEALTH MAINTENANCE ORGANIZATION
(HM) – This is only for the first
occurrence. On subsequent occurrences,
fill out as appropriate.
OTHER NON-FEDERAL PROGRAMS
TO USE.
SEE X12 IG
FOR
ADDT’L
CODES/
VALUES
CAS
CLAIM LEVEL ADJUSTMENTS
C1
CAS01
CLAIM ADJUSTMENT GROUP
CODE
Y
CO
CR
OA
PI
PR
CAS02
CAS03
CAS04
CAS05
CAS06
CAS07
CAS08
CAS09
CAS10
CAS11
CAS12
CAS13
CAS14
CAS15
CAS16
CAS17
CAS18
CAS19
AMT
COB PAYER PAID AMOUNT
CLAIM ADJUSTMENT REASON
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
COMPLETE IF YOU HAVE CLAIM LEVEL
ADJUSTMENTS
CONTRACTUAL OBLIGATIONS
Y
CORRECTIONS AND REVERSALS
OTHER ADJUSTMENTS
PAYOR INITIATED REDUCTIONS
PATIENT RESPONSIBILITY
ADJUSTMENT REASON
Y
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
ADJUSTMENT REASON
C1
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
ADJUSTMENT REASON
C1
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
ADJUSTMENT REASON
C1
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
ADJUSTMENT REASON
C1
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
ADJUSTMENT REASON
C1
C1
C2
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
16
LOOP
SEGMENT
NAME
ID
AMT01
AMT02
AMT
AMT
OI
REQ
VALUE(S)
MONETARY AMOUNT
Y
Y
D
PAYOR PAID AMOUNT
PAYER PAID AMOUNT; ZERO IS
ACCEPTABLE
REMAINING PATIENT
LIABILITY
C1
AMT01
AMT02
MONETARY AMOUNT
Y
Y
C1
EAF
AMOUNT OWED
REMAINING PATIENT LIABILITY
AMT01
AMT02
MONETARY AMOUNT
Y
Y
Y
A8
NONCOVERED CHARGES – ACTUAL
NON-COVERED CHARGE AMOUNT
OI03
YES/NO CONDITION OR
RESPONSE
PATIENT SIGNATURE SOURCE
CODE
Y
Y
C1
P
Y
C2
Y
COB TOTAL NON-COVERED
AMOUNT
OTHER INSURANCE
COVERAGE INFORMATION
OI04
OI06
2330A
OTHER SUBSCRIBER NAME
NM1
NM101
NM102
ENTITY ID CODE
NM103
NAME
NAME FIRST
NAME MIDDLE
NAME SUFFIX
ID CODE QUALIFIER
ID CODE
NM104
NM105
NM107
NM108
NM109
DHS Encounter Data
ELEMENT NAME
Y
Y
Y
Y
C1
C1
C1
Y
Y
SIGNATURE GENERATED BY PROVIDER
AS THE PATIENT WAS NOT PHYSICALLY
PRESENT FOR SERVICES
REQUIRED – MCO ADJUDICATION
INFORMATION AS A PAYER IS
SUBMITTED HERE AND TPL
ADJUDICATION INFORMATION,
INCLUDING PHYSICIAN ADMINISTERED
DRUGS. ONE SUBSCRIBER NAME PER
SBR SEGMENT.
IL
1
2
UNKNOWN
MI
UNKNOWN
PERSON
NON-PERSON ENTITY
OTHER INSURED LAST NAME
OTHER INSURED FIRST NAME
OTHER INSURED MIDDLE INITIAL NAME
OTHER INSURED NAME SUFFIX
17
LOOP
SEGMENT
2330B
NAME
ID
ELEMENT NAME
OTHER PAYER NAME
NM1
OTHER PAYER NAME
NM108
NM109
SV1
PROFESSIONAL SERVICE
PAYER
NON-PERSON ENTITY
Y
PI
PAYOR IDENTIFICATION
OTHER PAYER PRIMARY IDENTIFIER
DHS UMPI NUMBER ASSIGNED TO THE
MANAGED CARE ORGANIZATION
Y
Y
REF02
QUALIFIER
LX01
ASSIGNED NUMBER
SV101
COMPOSITE MEDICAL
PROCEDURE IDENTIFIER
PRODUCT/SERVICE ID
QUALIFIER
SV1011
PR
2
UNKNOWN
Y
Y
REF01
LX
DRUGS. ONE OTHER PAYER NAME PER
SBR SEGMENT.
Y
Y
Y
Y
DATE/TIME QUALIFIER
QUALIFIER
DATE TIME PERIOD
OTHER PAYER CLAIM
CONTROL NUMBER
SERVICE LINE
SERVICE LINE
C1
DTP03
2400
NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
CLAIM CHECK OR
REMITTANCE DATE
DTP01
DTP02
REF
VALUE(S)
C2
NM101
NM102
NM103
DTP
DHS Encounter Data
REQ
573
D8
DATE CLAIM PAID
F8
ADJUDICATION OR PAYMENT DATE
MUST BE USED FOR MEDICARE
CLAIMS.
Y
C1
Y
Y
Y
Y
Y
Y
Y
MEDICARE ICN
BEGIN WITH 1 AND INCREMENT BY 1.
HC
HCPCS/CPT CODE
18
LOOP
SEGMENT
NAME
ID
REQ
SV1012
SV1013
SV1014
SV1015
SV1016
PRODUCT/SERVICE ID
Y
HCPCS/CPT PROCEDURE CODE
PROCEDURE MODIFIER
C1
MODIFIER 1
PROCEDURE MODIFIER
C1
MODIFIER 2
PROCEDURE MODIFIER
C1
MODIFIER 3
PROCEDURE MODIFIER
C1
MODIFIER 4
SV1017
DESCRIPTION
C1
SV102
MONETARY AMOUNT
Y
DESCRIPTION OF NON SPECIFIC, (NOC),
UNLISTED, UNCLASSIFIED OR
MISCELLANEOUS CODES WHEN
REPORTED IN SV101-2. YOU SHOULD
ALSO REPORT THE HEARING AID
MODEL NUMBER IN THIS DATA
ELEMENT (NOT IN THE L2300/K3
SEGMENT).
LINE ITEM CHARGE AMOUNT. PER
SV103
UNIT/BASIS OF MEASUREMENT
CODE
Y
SV104
SV105
QUANTITY
FACILITY CODE VALUE
Y
C1
SV107
COMP. DIAGNOSIS CODE
POINTER
DIAGNOSIS CODE POINTER
Y
C1
C1
SV1071
SV1072
SV1073
DHS Encounter Data
ELEMENT NAME
Y
VALUE(S)
UN
UNITS
MJ
MINUTES-USED FOR ANESTHESIA
CLAIMS
UNITS OF SERVICE
OVERRIDE CLM05-1 IN LOOP 2300 WHEN
PLACE OF SERVICE IS DIFFERENT THAN
THE VALUE SENT AT THE CLAIM LEVEL.
POINTER TO RELATED DIAGNOSIS
CODE
CODE
CODE
19
LOOP
SEGMENT
DTP
NAME
ID
REQ
SV1074
SV109
C1
YES/NO CONDITION OR
RESPONSE CODE
DTP01
DTP02
DATE/TIME QUALIFIER
QUALIFIER
DATE – SERVICE DATE
DTP03
DTP
QTY
REF
DATE TIME PERIOD
CERTIFICATION REVISION
DATE
DTP01
DTP02
DTP03
RECERTIFICATION DATE
QTY01
QTY02
QUANTITY QUALIFIER
QUANTITY
AMBULANCE PATIENT COUNT
REPRICED LINE ITEM
REFERENCE NUMBER
C1
Y
CODE
EMERGENCY RELATED
Y
Y
Y
472
D8
SERVICE DATE(S)
RD8
DATE EXPRESSED IN CCYYMMDDCCYYMMDD
SERVICE DATE(S)
Y
Y
Y
Y
C2
Y
Y
607
D8
MCO PAID DATE
PAID DATE
DATE OF PAYMENT TO PROVIDER FOR
PHYSICIAN ADMINISTERED DRUGS.
PT
PATIENTS
AMBULANCE PATIENT COUNT.
REQUIRED WHEN MORE THAN ONE
PATIENT IS TRANSPORTED IN THE
SAME VEHICLE FOR AMBULANCE OR
NON-EMERGENCY TRANSPORTATION
SERVICES.
9B
ALLOWED AMOUNT
C2
REF02
QUALIFIER
MONETARY AMOUNT
ADJUSTED REPRICED LINE
ITEM REFERENCE NUMBER
Y
Y
ALLOWED AMOUNT IS THE PROVIDER
CONTRACTED RATE PRIOR TO ANY
EXCLUSIONS OR ADD-ONS. SEE
APPENDIX – P. 77
C2
REF01
VALUE(S)
C2
REF01
REF
DHS Encounter Data
ELEMENT NAME
QUALIFER
Y
9D
PAID AMOUNT
20
LOOP
SEGMENT
NAME
ID
REF02
2410
REQ
MONETARY AMOUNT
Y
DRUG IDENTIFICATION
LIN
2420A
ITEM IDENTIFICATION
LIN03
CTP04
QUANTITY
C2
Y
CTP05
COMPOSITE UNIT OF MEASURE
Y
CTP051
UNIT OR BASIS OF
MEASUREMENT CODE
Y
DRUG PRICING
THE AMOUNT PAID TO THE PROVIDER
EXCLUDING THIRD PARTY LIABILITY,
PROVIDER WITHHOLDS AND
INCENTIVES, AND MEMBER COST
SHARING. SEE APPENDIX – P. 77
USED WHEN PROC CODE MATCHES
ONE ON LIST: HCPCS REQUIRING NDC
Y
N4
Y
NATIONAL DRUG CODE
NDC CODE FOR PHYSICIAN
ADMINISTERED DRUGS.
F2
DRUG QUANTITY FOR PHYSICIAN
ADMINISTERED DRUGS.
UNIT OR BASIS FOR MEASUREMENT
CODE
INTERNATIONAL UNIT
GR
GRAM
ME
MILLIGRAM
ML
MILLILITER
UN
UNIT
C1
OVERRIDE 2310B LOOP IF THE
RENDERING PROVIDER ON A LINE ITEM
IS DIFFERENT THAN THE NUMBER
SUBMITTED AT THE CLAIM LEVEL.
NM101
NM102
Y
Y
NM103
NAME
NAME FIRST
Y
C1
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
Y
ANY TEXT- REQUIRED IF “1” IS SENT IN
NM102.
NPI
NM104
NM108
NM109
REF
C2
PRODUCT/SERVICE ID
QUALIFIER
PRODUCT SERVICE ID
NM1
VALUE(S)
C2
LIN02
CTP
DHS Encounter Data
ELEMENT NAME
Y
C1
82
1
2
XX
RENDERING PROVIDER
PERSON
NON-PERSON
RENDERING PROVIDER NPI
21
LOOP
SEGMENT
2430
NAME
ID
REQ
VALUE(S)
REF01
QUALIFIER
Y
G2
REF02
Y
C2
LINE ADJUDICATION
INFORMATION
SVD
LINE ADJUDICATION
INFORMATION
DOLLAR AMOUNT OF ALL TPL AND/OR
MEDICARE PAYMENT INFORMATION.
SVD01
IDENTIFICATION CODE
Y
SVD02
MONETARY AMOUNT
Y
SVD03
COMPOSITE MEDICAL
PROCEDURE
PRODUCT/SERVICE ID
QUALIFIER
PRODUCT SERVICE ID
Y
Y
HCPCS PROCEDURE CODE
PROCEDURE MODIFIER
C1
MODIFIER 1
PROCEDURE MODIFIER
C1
MODIFIER 2
PROCEDURE MODIFIER
C1
MODIFIER 3
PROCEDURE MODIFIER
C1
MODIFIER 4
QUANTITY
Y
C1
Y
UNITS OF SERVICE
LINE ADJUSTMENT
CAS01
DHS UMPI NUMBER.
DRUGS. UP TO 15 OF THIS LOOP CAN
BE SENT; SEND ONE PER
L2330B/NM1*PR SEGMENT.
Y
SVD031
SVD032
SVD033
SVD034
SVD035
SVD036
SVD05
CAS
DHS Encounter Data
ELEMENT NAME
CODE
Y
HC
CO
HCPCS CODE
22
LOOP
SEGMENT
NAME
ID
CAS02
CAS03
CAS04
CAS05
CAS06
CAS07
CAS08
CAS09
CAS10
CAS11
CAS12
CAS13
CAS14
CAS15
CAS16
CAS17
CAS18
CAS19
DTP
TRL
SE
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
DATE OR TIME OR PERIOD
DTP01
DTP02
AMT
ELEMENT NAME
DTP03
DATE/TIME QUALIFIER
QUALIFIER
DATE TIME PERIOD
AMT01
AMT02
MONETARY AMOUNT
SE01
NUMBER OF INCLUDED
SEGMENTS
REMAINING PATIENT
LIABILITY
TRAILER
TRANSACTION SET TRAILER
DHS Encounter Data
REQ
VALUE(S)
CR
OA
PI
PR
Y
CORRECTION AND REVERSALS
OTHER ADJUSTMENTS
ADJUSTMENT REASON CODE
Y
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
Y
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
Y
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
Y
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
Y
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
Y
C1
Y
C2
Y
Y
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
MEDICARE OR PAYER PAID DATE
573
D8
DATE CLAIM PAID
CCYYMMDD
ENTER ADJUDICATION DATE
EAF
AMOUNT OWED
Y
C1
Y
Y
Y
Y
TOTAL SEGMENTS IN TRANSACTION
SET.
23
LOOP
SEGMENT
NAME
ID
SE02
DHS Encounter Data
ELEMENT NAME
REQ
NUMBER
Y
VALUE(S)
MUST MATCH ST02.
24
ENVELOPE INFORMATION
INTERCHANGE CONTROL HEADER
REFERENCE
DESCRIPTION
ISA01
ELEMENT DESCRIPTION
837P VALUES
DO NOT SEND SEGMENT DELIMITERS THAT ARE MORE THAN ONE BYTE. SEE APPENDIX A.1.2.4
THROUGH A.1.2.7 IN THE 837 IMPLEMENTATION GUIDE FOR LISTS OF CHARACTERS THAT ARE
ALLOWED. IF YOU SEND CHARACTERS THAT ARE NOT WITHIN THE SETS SHOWN IN THE GUIDE,
YOUR FILE WILL NOT BE PROCESSED. QUALIFIER VALUES ARE CASE SENSITIVE. IF LOWER CASE
VALUES ARE SENT, YOUR FILE WILL NOT BE PROCESSED. PLEASE SEND ONE INTERCHANGE PER
FILE UNTIL FURTHER NOTICE. IF YOU SEND MORE THAN ONE INTERCHANGE, THE ADDITIONAL
INTERCHANGES MAY NOT BE PROCESSED.
00-NO AUTHORIZATION INFORMATION PRESENT.
ISA02
ISA03
AUTHORIZATION INFORMATION
QUALIFIER
SECURITY INFORMATION QUALIFIER
ISA04
ISA05
ISA06
SECURITY INFORMATION
INTERCHANGE ID QUALIFIER
INTERCHANGE SENDER ID
ISA07
ISA08
INTERCHANGE RECEIVER ID
ISA09
INTERCHANGE DATE
10 SPACES
ZZ-MUTUALLY DEFINED
THIS NUMBER MUST BE THE ONE USED TO REGISTER IN THE MN-ITS SYSTEM AND MUST
CORRESPOND TO THE MN-ITS MAILBOX NUMBER. THIS MUST CHANGE TO THE 10-DIGIT NATIONAL
PROVIDER IDENTIFIER (NPI) OR UNIVERSAL MINNESOTA PROVIDER IDENTIFIER (UMPI) FOLLOWED
BY 5 TRAILING SPACES.
30-U.S. FEDERAL TAX IDENTIFICATION NUMBER
41-1674742-MN DEPT OF HUMAN SERVICES FEIN FOLLOWED BY 5 TRAILING SPACES. THIS NUMBER
MUST CONTAIN A HYPHEN.
CURRENT DATE FORMATTED AS 6-DIGITS (YYMMDD)
ISA10
ISA11
INTERCHANGE TIME
REPETITION SEPARATOR
CURRENT TIME FORMATTED AS 4-DIGITS(HHMM)
PLEASE SEND DHS “[“
ISA12
00501-DRAFT STANDARDS FOR TRIAL USE APPROVED ASC X-12 REVIEW BOARD
ISA13
INTERCHANGE CONTROL VERSION
NUMBER
INTERCHANGE CONTROL NUMBER
ISA14
ISA15
ISA16
ACKNOWLEDGMENT REQUESTED
USAGE INDICATOR
COMPONENT ELEMENT SEPARATOR
PROVIDER OPTION 0-NO OR 1-YES.
SEND P-PRODUCTION DATE FOR PRODUCTION FILES AND T-TEST DATA FOR TEST FILES.
PROVIDER OPTION/SUB-ELEMENT DELIMITER.
10 SPACES
00-NO SECURITY INFORMATION PRESENT
BEGIN WITH "1" 9-DIGIT ZERO FILLED LEFT TO RIGHT. ALL ZEROS IS NOT AN ALLOWED VALUE.
25
INTERCHANGE CONTROL TRAILER
REFERENCE
DESCRIPTION
IEA01
IEA02
ELEMENT DESCRIPTION
NUMBER OF INCLUDED FUNCTIONAL
GROUPS
837P VALUES
PROVIDER TRANSLATOR COUNTS NUMBER OF FUNCTIONAL GROUPS WITHIN THE
INTERCHANGE.
SAME AS ISA13
FUNCTIONAL GROUP HEADER
REFERENCE
DESCRIPTION
GS01
GS02
ELEMENT DESCRIPTION
FUNCTIONAL IDENTIFIER CODE
APPLICATION SENDER’S CODE
GS03
GS04
GS05
APPLICATION RECEIVER’S CODE
FUNCTIONAL GROUP CREATION DATE
CREATION TIME
GS06
GROUP CONTROL NUMBER
GS07
GS08
RESPONSIBLE AGENCY CODE
VERSION/RELEASE/INDUSTRY
IDENTIFIER CODE
837P VALUES
HC-HEALTH CARE CLAIMS (837)
THIS MUST CHANGE TO 10-DIGIT NATIONAL PROVIDER IDENTIFIOER OR UNIVERSAL MINNESOTA
PROVIDER IDENTIFIER (UMPI). MUST MATCH THE NUMBER IN ISA06 WITHOUT THE TRAILING
SPACES.
41-1674742-MN DEPT OF HUMAN SERVICES FEIN. THIS NUMBER MUST CONTAIN A HYPHEN.
CURRENT DATE FORMATTED AS 8-DIGITS (CCYYMMDD).
CURRENT TIME FORMATTED AS 4-DIGITS (HHMM).
UNIQUE 1-DIGIT TO 9-DIGIT NUMBER. PREFERABLY START AT 1 AND INCREMENT BY 1 FOR EACH
SUCCESSIVE FUNCTIONAL GROUP FROM SENDER TO RECEIVER, AND NOT RESET TO STARTING
VALUE OF 1 WITHIN EACH INTERCHANGE OR EACH DAY.
X-ACCREDITED STANDARDS COMMITTEE X-12
005010X222A1DRAFT STANDARDS APPROVED BY ASC X12 BOARD.
FUNCTIONAL GROUP TRAILER
REFERENCE
DESCRIPTION
GE01
GE02
ELEMENT DESCRIPTION
NUMBER OF TRANSACTION SETS
INCLUDED
837P VALUES
1 - 6 DIGITS. PROVIDER TRANSLATOR COUNTS NUMBER OF TRANSACTION SETS WITHIN THE
FUNCTIONAL GROUP.
MUST MATCH GS06 NUMBER.
26
3 INSTITUTIONAL
DHS Encounter Data
837I HIPAA Implementation Guide Data
LOOP
HDR
SEG
ST
NAME
HEADER
ID
ST01
ST02
ST03
BHT
TRANSACTION SET IDENTIFIER
CODE
NUMBER
IMPLEMENTATION
CONVENTION REFERENCE
BEGIN OF HIERARCHICAL TXN
BHT01
BHT02
1000A
ELEMENT NAME
CODE
TRANSACTION SET PURPOSE
CODE
BHT03
BHT04
BHT05
BHT06
DATE
TIME
TRANSACTION TYPE CODE
NM101
NM102
NM103
NAME LAST OR
ORGANIZATION NAME
IDENTIFICATION CODE
QUALIFIER
SUBMITTER NAME
NM1
SUBMITTER NAME
NM108
PER
NM109
IDENTIFICATION CODE
PER01
PER02
PER03
CONTACT FUNCTION CODE
NAME
QUALIFIER
SUBMITTER EDI CONTACT INFO
PER04
REQ
Y
Y
Y
VALUE
DESCRIPTION
837
HEALTH CARE CLAIM
Y
Y
005010
X223A2
837I VERSION NUMBER
Y
Y
0019
Y
00
INFORMATION SOURCE, SUBSCRIBER
DEPENDENT
ORIGINAL
Y
Y
Y
Y
Y
Y
18
RP
REISSUE
SUBMISSION NUMBER-MCO ASSIGNED
REPORTING
THIS LOOP IS USED FOR INFORMATION
REGARDING THE MCO RESPONSIBLE
FOR THE ENCOUNTER.
Y
Y
Y
Y
41
2
SUBMITTER
NON-PERSON ENTITY
MCO (OR CONTRACTOR) NAME
Y
46
TRADING PARTNER ID
Y
Y
Y
Y
Y
Y
MCO UMPI NUMBER
IC
TE
INFORMATION CONTACT
TELEPHONE
27
DHS Encounter Data
LOOP
1000B
SEG
NM1
NAME
RECEIVER NAME
RECEIVER NAME
ID
NM101
NM102
NM103
NM108
NM109
2000A
HL
NM1
BILLING PROVIDER SPECIALTY
INFORMATION
DESCRIPTION
40
2
RECEIVER
NON-PERSON ENTITY
Y
46
TRADING PARTNER ID
Y
411674
742
RECEIVER ID
Y
Y
Y
Y
20
1
PRV03
PROVIDER CODE
QUALIFIER
NM101
NM102
NM103
NAME LAST OR
ORGANIZATION NAME
Y
Y
2
NM108
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
C1
XX
VALUE
1 THEN INCREMENT BY 1.
INFORMATION SOURCE
STRUCTURE
C1
NM109
N3
REQ
Y
Y
Y
Y
Y
Y
PRV01
PRV02
2010AA
NAME LAST OR
ORGANIZATION NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
HIERARCHICAL LEVEL
HIERARCHICAL LEVEL
HL01
HL03
HL04
PRV
ELEMENT NAME
Y
Y
BI
PXC
Y
Y
Y
Y
BILLING
CODE
85
BILLING PROVIDER
guide.
PAY TO PROVIDER
NON-PERSON ENTITY
PROVIDER ORGANIZATIONAL NAME
CMS NATIONAL PROVIDER IDENTIFIER
(NPI)
NATIONAL PROVIDER IDENTIFIER (NPI)
C1
Y
28
DHS Encounter Data
LOOP
SEG
N4
REF
NAME
ID
N301
ELEMENT NAME
ADDRESS INFORMATION
REQ
Y
N302
ADDRESS INFORMATION
C1
Y
N401
CITY NAME
Y
N402
C1
N403
POSTAL CODE
C1
BILLING
PROVIDERCITY/STATE/ZIP
BILLING/PAY TO PROVIDER TAX
IDENTIFICATION
HL
SBR
NM1
Y
Y
Y
LEVEL
HIERARCHICAL LEVEL
EMPLOYER IDENTIFICATION NUMBER OR
DEFAULT TO ANY NUMBER REQUIRED
BY STANDARD
ID NUMBER
Y
Y
HL02
HIERARCHICAL PARENT ID
Y
HL03
HL04
Y
Y
22
0
SBR01
Y
Y
U
UNKNOWN
Y
18
SELF
SBR09
CODE
CLAIM FILE INDICATOR CODE
MC
MEDICAID
NM101
Y
Y
Y
Y
IL
SUBSCRIBER NAME
SUBSCRIBER NAME
EI
HL01
SBR02
2010BA
QUALIFIER
DESCRIPTION
NAME
PROVINCE CODE
POSTAL ZONE OR ZIP CODE
BILLING PROVIDER TAX IDENTIFICATION
Y
REF01
2000B
VALUE
PROVIDER HL01 VALUE WHEN PROVIDER
NUMBER CHANGES IN A TRANSACTION
SET.
SUBSCRIBER
NO SUBORDINATE HL SEGMENT IN THIS
29
DHS Encounter Data
LOOP
SEG
NAME
ID
NM102
NM103
NM104
NM105
NM108
2010BA
ELEMENT NAME
NAME LAST OR
ORGANIZATION NAME
NAME FIRST
NM109
NAME MIDDLE
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
N301
ADDRESS INFORMATION
SUBSCRIBER ADDRESS
N3
2010BA
N4
DMG
REF
SUBSCRIBER ADDRESS
N401
SUBSCRIBER CITY
Y
N402
SUBSCRIBER STATE
Y
N403
SUBSCRIBER ZIP CODE
DMG0
1
DMG0
2
DMG0
3
DATE TIME FORMAT
QUALIFIER
DATE TIME PERIOD
Y
Y
Y
GENDER CODE
PROPERTY AND CASUALTY CLAIM
NUMBER
PAYER NAME
PAYER NAME
MI
DEFAULT TO ANY TEXT – NOT USED BUT
REQUIRED BY STANDARD.
DEFAULT TO “00000”
D8
Y
Y
MEMBER MIDDLE INITIAL, IF KNOWN
MEMBER ID NUMBER
DHS ASSIGNED EIGHT DIGIT MEMBER ID
C1
Y
Y
DESCRIPTION
PERSON
MEMBER LAST NAME
MEMBER FIRST NAME
Y
C2
SUBSCRIBER CITY, STATE, ZIP
CODE
U
UNKNOWN (DEFAULT)
F
M
FEMALE
MALE
Y4
AGENCY CLAIM NUMBER
C2
REF02
NM1
C1
Y
C2
VALUE
1
C1
SUBSCRIBER CITY/STATE/ZIP
REF01
2010BB
REQ
Y
Y
QUALIFIER
Y
Y
Y
y
MCO’S OWN MEMBER NUMBER
30
DHS Encounter Data
LOOP
SEG
NAME
ID
NM101
NM102
NM103
NM108
NM109
REF
2300
CLM
ELEMENT NAME
NAME LAST OR
ORGANIZATION NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
BILLING PROVIDER SECONDARY
IDENTIFICATION
REF01
QUALIFIER
REF02
CLM01
CLAIM SUBMITTER’S
IDENTIFIER
MONETARY AMOUNT
CLAIM INFORMATION
CLAIM INFORMATION
CLM02
CLM05
CLM05
-1
CLM05
-2
CLM05
-3
REQ
Y
Y
Y
VALUE
PR
2
DESCRIPTION
PAYER
NON-PERSON ENTITY
Y
PI
PAYER ID
Y
411674
742
DHS PAYER ID
G2
UMPI)
C1
Y
Y
Y
Y
Y
Y
TOTAL CLAIM CHARGE AMOUNT (BILLED
AMOUNT) PER APPENDIX A IN THE
IMPLEMENTATION GUIDE, DECIMAL DATA
ELEMENTS IN DATA ELEMENT 782 WILL
BE LIMITED TO A MAXIMUM LENGTH OF
10 CHARACTERS INCLUDING REPORTED
OR IMPLIED PLACES FOR CENTS. MUST
BE GREATER THAN OR EQUAL TO ZERO
HEALTH CARE SERVICE
LOCATION INFORMATION
FACILITY CODE VALUE
Y
FACILITY CODE VALUE
Y
FIRST TWO DIGITS OF THE TYPE OF BILL
FACILITY CODE QUALIFIER
Y
CLAIM FREQUENCY TYPE
CODE
Y
A
1
UNIFORM BILLING CLAIM FORM BILL
TYPE
CLAIM FREQUENCY TYPE CODE, CODE
SPECIFYING THE FREQUENCY OF THE
CLAIM; THIS IS THE THIRD POSITION OF
THE UNIFORM BILLING CLAIM FORM BILL
TYPE CODE SOURCE 235
ADMIT THRU DISCHARGE
31
DHS Encounter Data
LOOP
SEG
NAME
ID
ELEMENT NAME
REQ
CLM06
YES/NO CONDITION OR
RESPONSE CODE (PROVIDER
SIGNATURE ON FILE)
N/U
CLM07
PROVIDER ACCEPT
ASSIGNMENT CODE
C1
CLM08
CLM09
YES/NO CONDITION OR
RESPONSE CODE
CODE
Y
Y
VALUE
2
DESCRIPTION
INTERIM-FIRST CLAIM
3
INTERIM-CONTINUING CLAIM
4
INTERIM-LAST CLAIM
5
LATE CHARGES
7
8
REPLACEMENT
VOID
THIS DATA ELEMENT IS NO LONGER
USED.
N
A
NO
ASSIGNED (DEFAULT)
B
C
ACCEPTS ASSIGNMENT ON CLINICAL
LAB SERVICES ONLY
NOT ASSIGNED
Y
YES (DEFAULT)
N
NO
W
NOT APPLICABLE (USE W FOR PATIENT
REFUSAL)
CLAIM (DEFAULT)
INFORMED CONSENT TO RELEASE
MEDICAL INFORMATION FOR
CONDITIONS OR DIAGNOSES
REGULATED BY FEDERAL STATUTES.
Y
I
DTP
DISCHARGE HOUR
C1
Y
DTP01
DATE/TIME QUALIFIER
Y
096
DISCHARGE
DTP02
QUALIFIER
DATE TIME PERIOD
Y
TM
TIME EXPRESSED IN FORMAT HHMM
DTP03
Y
DISCHARGE TIME
VALUE CAN BE DEFAULTED TO 00.
32
DHS Encounter Data
LOOP
SEG
DTP
DTP
NAME
STATEMENT DATES
ID
DTP01
DTP02
DATE/TIME QUALIFIER
QUALIFIER
DTP03
DATE TIME PERIOD
DTP01
DTP02
DATE/TIME QUALIFIER
QUALIFIER
DATE TIME PERIOD
ADMISSION DATE/HOUR
DTP03
CL1
INSTITUTIONAL CLAIM CODE
CL101
CL102
CL103
AMT
REF
ELEMENT NAME
PRIORITY (TYPE) OF
ADMISSION OR VISIT
POINT OF ORIGIN FOR
ADMISSION OR VISIT
PATIENT STATUS
PATIENT ESTIMATED AMOUNT
DUE
PAYER CLAIM CONTROL NUMBER
REQ
Y
C1
Y
Y
Y
C1
Y
Y
VALUE
DESCRIPTION
434
RD8
STATEMENT
DATE EXPRESSED IN CCYYMMDDCCYYMMDD.
WHEN THE STATEMENT IS FOR A SINGLE
DATE OF SERVICE, THE FROM AND
THROUGH DATE ARE THE SAME.
STATEMENT FROM AND TO
435
DT
ADMISSION
DATE AND TIME EXPRESSED IN FORMAT
CCYYMMDDHHMM
ADMISSION DATE AND HOUR
Y
Y
Y
ADMISSION TYPE REQUIRED FOR ALL
INPATIENT AND OUTPATIENT SERVICES
ADMISSION SOURCE REQUIRED FOR ALL
INPATIENT AND OUTPATIENT SERVICES
PATIENT STATUS CODE LIST 239
C1: Follow HIPPA guide for all claims except
CD residential
C2: Required for CD residential treatment
claims
INFORMATION IS SENT IN THIS SEGMENT
WHETHER THE PAYMENT IS FROM THE
PATIENT OR THE PROVIDER.
C1
Y
C1
AMT01
AMOUNT CODE QUALIFIER
Y
AMT02
MONETARY AMOUNT
Y
F3
PATIENT RESPONSIBILITY IF
APPLICABLE
ENTER TOTAL TPL AND/OR MEDICARE
PAYMENT, IF APPLICABLE. PER
CHARACTERS INCLUDING REPORTED OR
IMPLIED PLACES FOR CENTS.
C1
33
DHS Encounter Data
LOOP
SEG
NAME
ID
REF01
REF02
REF
REPRICED CLAIM REFERENCE
NUMBER
REF02
QUALIFIER
REFERENCE INFORMATION
EPSDT REFERRAL
CRC01
CRC02
CRC03
CODE QUALIFIER
CERTIFICATION CONDITION
CODE APPLIES INDICATOR
CONDITION INDICATOR
PRINCIPAL DIAGNOSIS
HI01
VALUE
F8
DESCRIPTION
9A
USED WHEN CLM05-3 IS 7REPLACEMENT OR 8-VOID. THIS IS FOR
REPLACEMENT CLAIM OR VOID CLAIM
USAGE ONLY.
REQUIRED FIELD, THIS SEGMENT IS
USED FOR INPATIENT & OUTPATIENT
CLAIMS SEE APPENDIX – P. 77
ALLOWED AMOUNT
9C
THE ALLOWED AMOUNT IS THE
PROVIDER CONTRACTED RATE PRIOR
TO ANY EXCLUSIONS OR ADD-ONS. SEE
APPENDIX – P. 77
REQUIRED FIELD, THIS SEGMENT IS
USED FOR INPATIENT & OUTPATIENT
CLAIMS SEE APPENDIX – P. 77
PAID AMOUNT
ZZ
PAID AMOUNT IS THE AMOUNT PAID TO
THE PROVIDER EXCLUDING THIRD
PARTY LIABILITY, PROVIDER
WITHHOLDS, INCENTIVES, AND MEMBER
COST SHARING. SEE APPENDIX – P. 77
C&TC REFERRAL
MUTUALLY DEFINED
N
Y
NO
YES
AV
NU
S2
ST
AVAILABLE-NOT USED/ PATIENT
REFUSED REFERRAL
NOT USED
UNDER TREATMENT
NEW SERVICES REQUESTED
ABK
ICD-10-CM PRINCIPAL DIAGNOSIS CODE
C1
C2
Y
C2
REF02
HI
QUALIFIER
REFERENCE INFORMATION
ADJUSTED REPRICED CLAIM
NUMBER
REF01
CRC
REQ
C1
C2
REF01
REF
ELEMENT NAME
QUALIFIER
HEALTH CARE CODE
INFORMATION
C2
Y
C1
Y
Y
Y
Y
34
DHS Encounter Data
LOOP
SEG
HI
NAME
ID
ELEMENT NAME
REQ
HI01-2
Y
HI01-9
PRESENT ON ADMISSION
INDICATOR
C1
ADMITTING DIAGNOSIS
HI01-2
CODE LIST QUALIFIER
PRESENT ON ADMISSION INDICATOR
N
NO
U
UNKNOWN
W
NOT APPLICABLE
Y
YES
C1
ABJ
ICD-10-CM ADMITTING DIAGNOSIS CODE
BJ
ICD-9-CM ADMITTING DIAGNOSIS CODE
APR
ICD-10-CM PATIENTS REASON FOR VISIT
CODE
CODE
PATIENT REASON FOR VISIT
INDUSTRY CODE
PATIENTS REASON FOR VISIT
C1
HI01
HI01-1
HEALTH CARE CODE INFO
Y
Y
PR
HI01-2
INDUSTRY CODE
Y
HI02
THRU
HI03
HI02-1
THRU
HI1031
HEALTH CARE CODE INFO
C1
Y
APR
PR
HI02-2
THRU
HI1032
HI
INDUSTRY CODE
EXTERNAL CAUSE OF INJURY
Y
Correction of REQ value based on review of
X12 implementation guide. Only H101 is
required if this HI segment is used.
CODE
CODE
PATIENT REASON FOR VISIT
C1
HI01
DESCRIPTION
ICD-9-CM PRINCIPAL DIAGNOSIS CODE
DIAGNOSIS CODE.
C1
HI01-1
HI
VALUE
BK
HEALTH CARE CODE
INFORMATION
Y
35
DHS Encounter Data
LOOP
SEG
NAME
ID
HI01-1
ELEMENT NAME
REQ
Y
VALUE
ABN
BN
HI01-2
INDUSTRY CODE
Y
HI01-9
INDICATOR
C1
HI02
THRU
HI12
HI02-1
THRU
HI12-1
HI02-2
THRU
HI12-2
HI02-9
THRU
HI12-9
HI
HEALTH CARE CODE
INFORMATION
C1
Y
INDUSTRY CODE
Y
INDICATOR
C1
OTHER DIAGNOSIS INFORMATION
Y
HI01-1
HEALTH CARE CODE
INFORMATION
HI01-2
INDUSTRY CODE
Y
HI01-9
INDICATOR
C1
Y
NO
U
UNKNOWN
W
NOT APPLICABLE
Y
YES
ABN
ICD-10-CM EXTERNAL CAUSE OF INJURY
CODE
BN
CODE
EXTERNAL CAUSE OF INJURY CODE
N
NO
U
UNKNOWN
W
NOT APPLICABLE
Y
YES
C1
HI01
N
DESCRIPTION
CODE
CODE
EXTERNAL CAUSE OF INJURY CODE
DIAGNOSIS CODE.
ABF
ICD-10-CM OTHER DIAGNOSIS
BF
OTHER DIAGNOSIS
N
NO
U
UNKNOWN
36
DHS Encounter Data
LOOP
SEG
HI
NAME
ID
ELEMENT NAME
REQ
HI02
THRU
HI12
HI02-1
THRU
HI12-1
HEALTH CARE CODE
INFORMATION
C1
Y
HI02-2
THRU
HI12-2
HI02-9
THRU
HI12-9
INDUSTRY CODE
Y
INDICATOR
C1
PRINCIPAL PROCEDURE
INFORMATION
VALUE
W
Y
ABF
BF
OTHER DIAGNOSIS
N
NO
U
W
Y
UNKNOWN
NOT APPLICABLE
YES
BBR
ICD-10-PCS PRINCIPAL PROCEDURE
CODE
ICD-9- CM PRINCIPAL PROCEDURE
PRINCIPAL PROCEDURE CODE
CCYYMMDD
PRINCIPAL PROCEDURE DATE
C1
HI01
Y
HI01-1
HEALTH CARE CODE
INFORMATION
CODE LIST QUALIFIER
HI01-2
HI01-3
INDUSTRY CODE
DATE TIME PERIOD QUALIFIER
Y
C1
HI01-4
HI
DATE TIME PERIOD
C1
C1
HI01
Y
HI01-1
HEALTH CARE CODE
INFORMATION
HI01-2
INDUSTRY CODE
Y
HI01-3
QUALIFIER
Y
Y
BR
HI
OTHER PROCEDURE
INFORMATION
DESCRIPTION
NOT APPLICABLE
YES
Y
D8
BBQ
ICD-10-PCS OTHER PROCEDURE CODE
BQ
ICD-9-CM PROCEDURE
PROCEDURE CODE
D8
CCYYMMDD
37
DHS Encounter Data
LOOP
SEG
HI
NAME
OCCURRENCE SPAN
INFORMATION
ID
HI01-4
ELEMENT NAME
DATE TIME PERIOD
REQ
Y
VALUE
HI02
THRU
HI12
HI02-1
THRU
HI12-1
HEALTH CARE CODE
INFORMATION
C1
Y
HI02-2
THRU
HI12-2
HI02-3
THRU
HI12-3
HI02-4
THRU
HI12-4
HI
INDUSTRY CODE
Y
QUALIFIER
Y
DATE TIME PERIOD
Y
HI01
Y
HI01-1
HEALTH CARE CODE
INFORMATION
HI01-2
INDUSTRY CODE
Y
HI01-3
QUALIFIER
Y
HI01-4
DATE TIME PERIOD
Y
OCCURRENCE SPAN CODE DATE
HI02
THRU
HI12
HI02-1
THRU
HI12-1
HI02-2
THRU
HI12-2
HEALTH CARE CODE
INFORMATION
C1
Y
OCCURRENCE SPAN
INDUSTRY CODE
Y
BBQ
DESCRIPTION
PROCEDURE DATE
ICD-10-PCS OTHER PROCEDURE CODE
BQ
ICD-9-CM PROCEDURE
PROCEDURE CODE
D8
CCYYMMDD
PROCEDURE DATE
C1
Y
BI
OCCURRENCE SPAN
OCCURRENCE SPAN CODE
RD8
BI
RANGE OF DATES EXPRESSED IN
FORMAT CCYYMMDD-CCYYMMDD
OCCURRENCE SPAN CODE
38
DHS Encounter Data
LOOP
SEG
HI
NAME
OCCURRENCE INFORMATION
ID
HI02-3
THRU
HI12-3
HI02-4
THRU
HI12-4
HI
HI01
HI01-1
HI01-2
HI01-3
HI
VALUE INFORMATION
HI01-4
HI02
THRU
HI12
HI02-1
THRU
HI12-1
HI02-2
THRU
HI12-2
HI02-3
THRU
HI12-3
HI02-4
THRU
HI12-4
HI
HI01
ELEMENT NAME
QUALIFIER
REQ
Y
DATE TIME PERIOD
Y
HEALTH CARE CODE
INFORMATION
INDUSTRY CODE
QUALIFIER
DATE TIME PERIOD
HEALTH CARE CODE
INFORMATION
Y
Y
Y
INDUSTRY CODE
Y
QUALIFIER
Y
DATE TIME PERIOD
Y
HI01-2
INDUSTRY CODE
OCCURRENCE SPAN CODE DATE
BH
D8
Y
C1
Y
HI01-1
BH
MONETARY AMOUNT
OCCURRENCE
OCCURRENCE CODE
CCYYMMDD
OCCURRENCE CODE DATE
OCCURRENCE
OCCURRENCE CODE
D8
OCCURRENCE DATE
C2
Y
Y
BE
Y
Y
VALUE
VALUE CODE
80
81
HI01-5
DESCRIPTION
C1
Y
HEALTH CARE CODE
INFORMATION
VALUE
RD8
COVERED DAYS
NON-COVERED DAYS
VALUE CODE AMOUNT
39
DHS Encounter Data
LOOP
SEG
HI
NAME
CONDITION INFORMATION
ID
HI02
THRU
HI12
HI02-1
THRU
HI12-1
HI02-2
THRU
HI12-2
HI02-5
THRU
HI12-5
HI
HI01
HI01-1
HI01-2
HI02
THRU
HI12
HI02-1
THRU
HI12-1
HI02-2
THRU
HI12-2
2310A
ELEMENT NAME
HEALTH CARE CODE
INFORMATION
REQ
C2
VALUE
Y
BE
INDUSTRY CODE
Y
COVERED DAYS
NON-COVERED DAYS
VALUE CODE AMOUNT
Y
Y
C1
BG
Y
BG
CONDITION
CONDITION CODE
CONDITION
INDUSTRY CODE
Y
MONETARY AMOUNT
HEALTH CARE CODE
INFORMATION
INDUSTRY CODE
HEALTH CARE CODE
INFORMATION
Y
C1
Y
CONDITION CODE
C1
ATTENDING PHYSICIAN NAME
VALUE CODE
80
81
ATTENDING PHYSICIAN NAME
NM1
DESCRIPTION
VALUE
C1
Y
Y
NM101
NM102
NM103
ATTENDING PROVIDER LAST
NAME
Y
NM104
ATTENDING PROVIDER FIRST
NAME
C1
71
1
2
ATTENDING PHYSICIAN
PERSON
NON-PERSON X12 implementation guide
doesn’t support this qualifier.
DEFAULT TO ANY TEXT- REQUIRED IF “1”
IS SENT IN NM102.
40
DHS Encounter Data
LOOP
SEG
NAME
ID
NM108
NM109
REF
ATTENDING PHYSICIAN
REF02
NM1
NM104
NM108
NM109
REF02
NM1
OPERATING PHYSICIAN LAST
NAME
OPERATING PHYSICIAN FIRST
NAME
ID CODE QUALIFIER
ID CODE
REF01
2310D
QUALIFIER
OPERATING PHYSICIAN NAME
OPERATING PHYSICIAN NAME
NM101
NM102
NM103
REF
REQ
Y
Y
QUALIFIER
OPERATING PHYSICIAN
PRIMARY IDENTIFIER
Y
Y
C1
C1
Y
Y
Y
DESCRIPTION
NPI
ATTENDING PROVIDER PRIMARY
IDENTIFIER - NPI NUMBER IF “XX”
QUALIFIER IS ENTERED IN NM108.
G2
UMPI NUMBERS)
DHS UMPI NUMBER.
72
1
OPERATING PHYSICIAN
PERSON
REQUIRED IF “1” IS SENT IN NM102.
NPI
OPERATING PROVIDER NPI
Y
Y
Y
C21
Y
XX
G2
UMPI NUMBERS)
DHS UMPI NUMBER
Y
C1
C1
VALUE
XX
C2
REF01
2310B
ELEMENT NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
NM101
Y
82
RENDERING PROVIDER
NM102
Y
1
PERSON
NM103
Y
RENDERING PROVIDER LAST NAME
NM104
NAME LAST OR
ORGANIZATION NAME
NAME FIRST
C1
RENDERING PROVIDER FIRST NAME
NM105
NAME MIDDLE
C1
NM107
NAME SUFFIX
C1
RENDERING PROVIDER MIDDLE NAME
OR INITIAL
RENDERING PROVIDER NAME SUFFIX
NM108
IDENTIFICATION CODE
QUALFIER
Y
XX
NPI
41
DHS Encounter Data
LOOP
SEG
REF
NAME
ID
NM109
RENDERING PROVIDER
REF02
QUALIFIER
RENDERING PROVIDER
SECONDARY IDENTIFIER
NAME
NM1
REF
DESCRIPTION
RENDERING PROVIDER IDENTIFIER (NPI)
Y
G2
Y
RENDERING PROVIDER UMPI ID NUMBER
C1
THAN THAT CARRIED IN LOOP 2010AA
NM101
Y
77
SERVICE LOCATION
NM102
Y
2
NON-PERSON ENTITY
NM103
NAME LAST OR
ORGANIZATION NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
Y
NM109
N4
VALUE
NAME
NM108
N3
REQ
Y
C1
REF01
2310E
ELEMENT NAME
IDENTIFICATION CODE
ADDRESS
XX
C1
NPI
IDENTIFIER
Y
N301
ADDRESS INFORMATION
Y
N302
ADDRESS INFORMATION
C1
LINE
LINE
Y
N401
CITY NAME
Y
LABORATORY OR FACILITY CITY NAME
N402
C1
N403
POSTAL CODE
C1
PROVINCE CODE
ZONE OR ZIP CODE
C1
REF01
REF02
C1
QUALIFIER
Y
Y
G2
UMPI NUMBERS)
LABORATORY OR FACILITY SECONDARY
IDENTIFIER (DHS UMPI NUMBER)
42
DHS Encounter Data
LOOP
2320
SEG
NAME
OTHER SUBSCRIBER
INFORMATION
SBR
OTHER SUBSCRIBER
INFORMATION
ID
SBR01
SBR02
ELEMENT NAME
CODE
REQ
C2
Y
C1
Y
Y
VALUE
P
DESCRIPTION
REQUIRED – THE FIRST OCCURRENCE
MUST CONTAIN INFORMATION FOR THE
MCO AS THE PRIMARY/SECONDARY
PAYER. IF THE PRIMARY PAYER IS A
THIRD PARTY, THE SECOND
OCCURRENCE OF THIS SEGMENT
SHOULD CONTAIN A “P” AND
INFORMATION RELATED TO THE
RELEVANT THIRD PARTY PAYER. UP TO
10 SBR LOOPS CAN BE SENT.
Correction of REQ based on review of X12
implementation guide.
PRIMARY
S
SECONDARY
T
TERTIARY
SEE
X12 IG
FOR
ADDT’L
CODES
/VALUE
S
18
REFER TO THE IMPLEMENTATION GUIDE
FOR THE OTHER CODES/VALUES TO
USE.
SEE
X12 IG
FOR
ADDT’L
CODES
/VALUE
S
SBR03
C1
occurrence. Subsequent occurrences
should be billed as appropriate.
USE.
INSURED GROUP OR POLICY NUMBER
43
DHS Encounter Data
LOOP
SEG
NAME
ID
SBR04
ELEMENT NAME
NAME
REQ
C1
VALUE
DESCRIPTION
OTHER INSURED GROUP NAME
SBR09
CLAIM FILING INDICATOR
CODE
Y
C1
HM
11
HEALTH MAINTENANCE ORGANIZATION
(HM) – This is only for the first
occurrence. On subsequent occurrences,
fill out as appropriate.
X12 implementation guide.
USE.
SEE
X12 IG
FOR
ADDT’L
CODES
/VALUE
S
CAS
C1
CAS01
CAS02
Y
CO
CR
OA
OTHER ADJUSTMENTS
PI
PR
Y
CAS03
CODE
MONETARY AMOUNT
Y
ADJUSTMENT AMOUNT
CAS04
QUANTITY
C1
ADJUSTMENT QUANTITY
CAS05
C1
CAS06
CODE
MONETARY AMOUNT
C1
ADJUSTMENT AMOUNT
CAS07
QUANTITY
C1
ADJUSTMENT QUANTITY
CAS08
CODE
MONETARY AMOUNT
C1
C1
ADJUSTMENT AMOUNT
CAS09
CODE
ADJUSTMENTS. YOU CAN ADD UP TO 5
CAS SEGMENTS.
44
DHS Encounter Data
LOOP
SEG
AMT
AMT
AMT
OI
NAME
ID
CAS10
ELEMENT NAME
QUANTITY
REQ
C1
CAS11
C1
CAS12
CODE
MONETARY AMOUNT
C1
ADJUSTMENT AMOUNT
CAS13
QUANTITY
C1
ADJUSTMENT QUANTITY
CAS14
C1
CAS15
CODE
MONETARY AMOUNT
C1
ADJUSTMENT AMOUNT
CAS16
QUANTITY
C1
ADJUSTMENT QUANTITY
CAS17
C1
CAS18
CODE
MONETARY AMOUNT
C1
ADJUSTMENT AMOUNT
CAS19
QUANTITY
C1
ADJUSTMENT QUANTITY
DESCRIPTION
ADJUSTMENT QUANTITY
C2
AMT01
Y
AMT02
MONETARY AMOUNT
Y
D
PAYOR AMOUNT PAID
PAYER PAID AMOUNT
“0” ( ZERO) IS AN ACCEPTABLE AMOUNT
C1
AMT01
Y
AMT02
MONETARY AMOUNT
Y
AMOUNT
EAF
AMOUNT OWED
C1
AMT01
Y
AMT02
MONETARY AMOUNT
Y
OTHER INSURANCE COVERAGE
INFORMATION
A8
Y
OI03
OI06
VALUE
YES/NO CONDITION OR
RESPONSE
Y
Y
Y
Y
BENEFITS ASSIGNMENT CERTIFICATION
INDICATOR
CLAIM.
45
DHS Encounter Data
LOOP
2330A
SEG
NAME
NM1
ID
OTHER PAYER NAME
REQ
C2
VALUE
DESCRIPTION
FOR THE DRUGS. – MCO ADJUDICATION
SUBMITTER HERE AND TPL
DRUGS. ONE SUBSCRIBER NAME PER
SBR SEGMENT.
Y
NM101
ENTITY ID CODE
Y
IL
NM102
Y
1
PERSON
2
NON-PERSON ENTITY
UNKNO
WN
OTHER INSURED LAST NAME
NM103
2330B
ELEMENT NAME
Y
NM104
NAME LAST OR
ORGANIZATION NAME
NAME FIRST
C1
OTHER INSURED FIRST NAME
NM105
NAME MIDDLE
C1
OTHER INSURED MIDDLE NAME
NM107
NAME SUFFIX
C1
OTHER INSURED NAME SUFFIX
NM108
ID CODE QUALIFIER
Y
MI
NM109
ID CODE
Y
UNKNO
WN
C2
FOR THE DRUGS. – MCO ADJUDICATION
SUBMITTERED HERE AND TPL
DRUGS. ONE OTHER PAYER NAME PER
SBR SEGMENT.
46
DHS Encounter Data
LOOP
SEG
NM1
NAME
OTHER PAYER NAME
ID
ELEMENT NAME
REQ
Y
VALUE
DESCRIPTION
NM101
Y
PR
PAYER
NM102
Y
2
NON-PERSON ENTITY
NM103
NAME LAST OR
ORGANIZATION NAME
Y
UNKNO
WN
OTHER PAYER LAST OR ORGANIZATION
NAME
NM108
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
OTHER PAYER PRIMARY
IDENTIFIER
Y
PI
NM109
DTP
CLAIM CHECK OR REMITTANCE
DATE
C1
DTP01
DATE/TIME QUALIFIER
Y
573
DATE CLAIM PAID
DTP02
QUALIFIER
DATE TIME PERIOD
Y
D8
DTP03
REF
OTHER PAYER CLAIM CONTROL
NUMBER
REF01
REF02
2400
LX
SERVICE LINE NUMBER
SERVICE LINE NUMBER
SV2
INSTITUTIONAL SERVICE LINE
QUALIFIER
LX01
ASSIGNED NUMBER
SV201
SV202
PRODUCT/SERVICE ID
COMPOSITE MEDICAL
PRODUCT/SERVICE ID
QUALIFIER
PRODUCT/SERVICE ID
SV202
-1
SV202
-2
Y
Y
C1
MUST BE USED FOR MEDICARE CLAIMS.
Y
F8
Y
MEDICARE ICN
Y
Y
Y
Y
Y
C1
Y
Y
BEGIN WITH 1 AND INCREMENT BY 1.
SERVICE LINE REVENUE CODE
HC
HCPCS/CPT
HCPCS/CPT PROCEDURE CODE. IF
MEDICARE IS PRIMARY AND A MEDICARE
PAYMENT IS ENTERED ON THE CLAIM
AND MEDICARE DID NOT PROCESS THE
CLAIM WITH A PROCEDURE CODE, THE
HCPCS/CPT CODE DOES NOT HAVE TO
BE SENT.
47
DHS Encounter Data
LOOP
SEG
DTP
NAME
ID
SV202
-3
SV202
-4
SV202
-5
SV202
-6
SV203
ELEMENT NAME
PROCEDURE MODIFIER
REQ
C1
PROCEDURE MODIFIER
C1
MODIFIER 2
PROCEDURE MODIFIER
C1
MODIFIER 3
PROCEDURE MODIFIER
C1
MODIFIER 4
MONETARY AMOUNT
Y
CHARACTERS INCLUDING REPORTED OR
IMPLIED PLACES FOR CENTS.
SV204
UNIT OR BASIS OF
MEASUREMENT CODE
Y
SV205
SV207
QUANTITY
MONETARY AMOUNT
Y
C1
SERVICE DATE
DTP01
DTP02
DATE/TIME QUALIFIER
QUALIFIER
Y
C1
Y
Y
VALUE
DA
DAYS
UN
UNITS
SERVICE UNIT COUNT
LINE ITEM DENIED CHARGE OR NONCOVERED CHARGE AMOUNT
Correction of REQ based on review of X12
implementation guide.
SERVICE
CCYYMMDD
SERVICE DATE
THIS SEGMENT IS USED FOR INPATIENT
& OUTPATIENT CLAIMS.
ALLOWED AMOUNT
472
D8
RD8
REF
DTP03
DATE TIME PERIOD
Y
C2
REF01
QUALIFIER
REFERENCE IDENTIFIER
Y
REPRICED LINE ITEM REFERENCE
NUMBER
REF02
REF
ADJUSTED REPRICED LINE ITEM
REFERENCE NUMBER
Y
C2
DESCRIPTION
MODIFIER 1
9B
ALLOWED AMOUNT IS THE PROVIDER
CONTRACTED RATE PRIOR TO ANY
EXCLUSIONS OR ADD-ONS. SEE
APPENDIX – P. 77
THIS SEGMENT IS USED FOR
OUTPATIENT CLAIMS ONLY.
48
DHS Encounter Data
LOOP
SEG
NAME
ID
REF01
REF02
NTE
THIRD PARTY ORGANIZATION
NOTES
LIN
THIRD PARTY NOTES
Y
Y
C2
ITEM IDENTIFICATION
C2
LIN03
PRODUCT/SERVICE ID
QUALIFIER
PRODUCT/SERVICE ID
CTP03
UNIT PRICE
Y
Y
CTP04
NATIONAL DRUG UNIT COUNT
Y
CTP05
COMPOSITE UNIT OF
MEASURE
UNIT OR BASIS OF
MEASUREMENT CODE
Y
DRUG QUANTITY
CTP05
-1
VALUE
9D
Y
DRUG IDENTIFICATION
LIN02
CTP
REQ
Y
C2
NTE01
NTE02
2410
ELEMENT NAME
QUALIFIER
REFERENCE IDENTIFIER
Y
TPO
SINGLE
DATE
N4
Y
Y
DESCRIPTION
PAID AMOUNT
PAID AMOUNT IS THE AMOUNT PAID TO
THE PROVIDER EXCLUDING THIRD
WITHHOLDS, INCENTIVES, AND MEMBER
COST SHARING. SEE APPENDIX – P. 77
THIS SEGMENT IS USED FOR THE
PHYSICIAN ADMINISTERED DRUG
CLAIMS.
MCO PAID DATE
DATE OF THE PAYMENT TO THE
PROVIDER FOR PHYSICIAN
ADMINISTERED DRUGS. PAID DATE
MUST BE SENT AS
‘PAID DATE=20120101’.
USED WHEN PROC CODE MATCHES ONE
ON LIST: HCPCS CODES REQUIRING NDC
NATIONAL DRUG CODE (NDC)
NDC FOR PHYSICIAN ADMINISTERED
DRUGS.
DRUG UNIT PRICE NOT USED PER X12
IG
DRUG QUANTITY FOR PHYSICIAN
ADMINISTERED DRUGS.
F2
INTERNATIONAL UNIT
GR
GRAM
ME
MILLIGRAM
ML
MILLILITER
UN
UNIT
49
DHS Encounter Data
LOOP
2430
SEG
NAME
LINE ADJUDICATION
INFORMATION
SVD
LINE ADJUDICATION
INFORMATION
ID
VALUE
DESCRIPTION
FOR THE DRUGS. MCO ADJUDICATION
DRUGS. UP TO 15 OF THIS LOOP CAN BE
SENT, SEND ONE PER L2330B/NM1*PR
SEGMENT.
DOLLAR AMOUNT OF ALL TPL AND/OR
MEDICARE PAYMENT INFORMATION.
SVD01
IDENTIFICATION CODE
Y
SVD02
MONETARY AMOUNT
Y
SVD03
COMPOSITE MEDICAL
PRODUCT/SERVICE ID
QUALIFIER
PRODUCT SERVICE ID
Y
Y
PROCEDURE CODE
PROCEDURE MODIFIER
C1
MODIFIER 1
PROCEDURE MODIFIER
C1
MODIFIER 2
PROCEDURE MODIFIER
C1
MODIFIER 3
PROCEDURE MODIFIER
C1
MODIFIER 4
PRODUCT SERVICE ID
QUANTITY
Y
Y
C1
Y
SERVICE LINE REVENUE CODE
PAID SERVICE UNIT COUNT
LINE ADJUSTMENT
CAS01
REQ
C1
C2
C2
SVD03
-1
SVD03
-2
SVD03
-3
SVD03
-4
SVD03
-5
SVD03
-6
SVD04
SVD05
CAS
ELEMENT NAME
CODE
Y
HC
HCPCS/CPT CODE
CO
CR
OA
OTHER ADJUSTMENTS
50
DHS Encounter Data
LOOP
SEG
NAME
ID
ELEMENT NAME
REQ
Y
Y
C1
C1
ADJUSMENT AMOUNT
ADJUSTMENT QUANTITY
C1
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
C1
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
C1
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
C1
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
CAS18
CAS19
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
CODE
MONETARY AMOUNT
QUANTITY
DESCRIPTION
C1
C1
Y
C2
DTP01
DATE/TIME QUALIFIER
Y
573
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
Correction of segment title and REQ value
guide.
DATE CLAIM PAID
DTP02
Y
D8
DTP03
QUALIFIER
DATE TIME PERIOD
CCYYMMDD
AMT01
AMT02
MONETARY AMOUNT
EAF
AMOUNT OWED
CAS02
CAS03
CAS04
CAS05
CAS06
CAS07
CAS08
CAS09
CAS10
CAS11
CAS12
CAS13
CAS14
CAS15
CAS16
CAS17
DTP
AMT
TRL
SE
LINE CHECK OR REMITTANCE
DATE
TRAILER
Y
C1
Y
Y
VALUE
PI
PR
Y
51
DHS Encounter Data
LOOP
SEG
NAME
ID
SE01
SE02
ELEMENT NAME
NUMBER OF INCLUDED
SEGMENTS
NUMBER
REQ
Y
VALUE
Y
DESCRIPTION
TOTAL SEGMENTS IN TRANSACTION SET.
MUST MATCH ST02.
REFERENCE
DESCRIPTION
ELEMENT DESCRIPTION
837I VALUES
ISA01
DO NOT SEND SEGMENT DELIMITERS THAT ARE MORE THAN ONE BYTE. SEE APPENDIX
A.1.2.4 THROUGH A.1.2.7 IN THE 837 IMPLEMENTATION GUIDE FOR LISTS OF CHARACTERS
THAT ARE ALLOWED. IF YOU SEND CHARACTERS THAT ARE NOT WITHIN THE SETS
SHOWN IN THE GUIDE, YOUR FILE WILL NOT BE PROCESSED. QUALIFIER VALUES ARE
CASE SENSITIVE. IF LOWER CASE VALUES ARE SENT, YOUR FILE WILL NOT BE
PROCESSED. PLEASE SEND ONE INTERCHANGE PER FILE UNTIL FURTHER NOTICE. IF
YOU SEND MORE THAN ONE INTERCHANGE, THE ADDITIONAL INTERCHANGES MAY NOT BE
PROCESSED.
AUTHORIZATION INFORMATION QUALIFIER 00-NO AUTHORIZATION INFORMATION PRESENT.
ISA02
ISA03
ISA04
SECURITY INFORMATION QUALIFIER
10 SPACES
10 SPACES
ISA05
ISA06
ISA07
ZZ-MUTUALLY DEFINED
CORRESPOND TO THE MN-ITS MAILBOX NUMBER. THIS MUST CHANGE TO THE 10-DIGIT
NATIONAL PROVIDER IDENTIFIER (NPI) OR UNIVERSAL MINNESOTA PROVIDER IDENTIFIER
(UMPI) FOLLOWED BY 5 TRAILING SPACES.
30-U.S. FEDERAL TAX IDENTIFICATION NUMBER
ISA08
INTERCHANGE RECEIVER ID
ISA09
INTERCHANGE DATE
41-1674742-MN DEPT OF HUMAN SERVICES FEIN FOLLOWED BY 5 TRAILING SPACES. THIS
NUMBER MUST CONTAIN A HYPHEN.
ISA10
ISA11
INTERCHANGE TIME
ISA12
INTERCHANGE CONTROL VERSION
NUMBER
ISA13
BEGIN WITH "1" 9-DIGIT ZERO FILLED LEFT TO RIGHT. ALL ZEROS IS NOT AN ALLOWED
52
VALUE.
ISA14
ISA15
ACKNOWLEDGMENT REQUESTED
USAGE INDICATOR
ISA16
COMPONENT ELEMENT SEPARATOR
53
REFERENCE
DESCRIPTION
ELEMENT DESCRIPTION
837I VALUES
IEA01
NUMBER OF INCLUDED FUNCTIONAL PROVIDER TRANSLATOR COUNTS NUMBER OF FUNCTIONAL GROUPS WITHIN THE
GROUPS
INTERCHANGE.
IEA02
SAME AS ISA13
REFERENCE
ELEMENT DESCRIPTION
DESCRIPTION
GS01
GS02
837I VALUES
PROVIDER IDENTIFIER (UMPI). MUST MATCH THE NUMBER IN ISA06 WITHOUT THE TRAILING
SPACES.
GS03
GS04
FUNCTIONAL GROUP CREATION
DATE
GS05
CREATION TIME
GS06
UNIQUE 1-DIGIT TO 9-DIGIT NUMBER. PREFERABLY START AT 1 AND INCREMENT BY 1 FOR
EACH SUCCESSIVE FUNCTIONAL GROUP FROM SENDER TO RECEIVER, AND NOT RESET TO
STARTING VALUE OF 1 WITHIN EACH INTERCHANGE OR EACH DAY.
GS07
GS08
IDENTIFIER CODE
005010X223A2-DRAFT STANDARDS APPROVED BY ASC X12 BOARD.
REFERENCE
ELEMENT DESCRIPTION
DESCRIPTION
GE01
INCLUDED
GE02
837I VALUES
FUNCTIONAL GROUP.
54
4
DENTAL
837D HIPAA Implementation Guide Data
LOOP
HDR
SEG
ST
NAME
ID
HEADER
ST01
ST02
ST03
BHT
ELEMENT NAME
TRANSACTION SET
IDENTIFIER CODE
TRANSACTION SET
CONTROL NUMBER
IMPLEMENTATION
CONVENTION
REFERENCE
BEGIN OF HIERARCHICAL
TRANSACTION
DHS Information
REQ
VALUE
DESCRIPTION
Y
Y
837
HEALTH CARE CLAIM
Y
Y
005010X22
4A2
SAME AS GS08
INFORMATION SOURCE, SUBSCRIBER,
DEPENDENT
ORIGINAL
Y
BHT01
BHT02
HIERARCHICAL
STRUCTURE CODE
TRANSACTION SET
PURPOSE CODE
Y
0019
Y
00
REFERENCE
IDENTIFICATION
DATE
TIME
TRANSACTION TYPE
CODE
Y
REISSUE
SUBMISSION NUMBER- MCO ASSIGNED
Y
Y
Y
REPORTING
18
BHT03
BHT04
BHT05
BHT06
1000A
SUBMITTER NAME
NM1
Y
SUBMITTER NAME
NM101
NM102
NM103
NM104
NM105
NM108
NM109
RP
ENTITY IDENTIFIER
CODE
NAME LAST OR
ORGANIZATION NAME
NAME FIRST
NAME MIDDLE
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
Y
Y
Y
Y
N
N
Y
Y
THIS LOOP IS USED FOR
INFORMATION REGARDING THE MCO
RESPONSIBLE FOR THE ENCOUNTER.
41
SUBMITTER
2
NON-PERSON ENTITY
MCO NAME (OR CONTRACTOR)
46
NOT REQUIRED
NOT REQUIRED
TRADING PARTNER ID
DHS CONTRACT ID/UMPI NUMBER OF
THE MCO
55
LOOP
SEG
PER
NAME
SUBMITTER EDI CONTACT
INFORMATION
ID
PER01
PER02
PER03
PER04
1000B
NM1
NM108
NM109
HL03
HL04
Y
IC
INFORMATION CONTACT
C1
Y
TE
TELEPHONE
COMMUNICATION
NUMBER
Y
ENTITY IDENTIFIER
CODE
NAME LAST OR
ORGANIZATION NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
HIERARCHICAL ID
NUMBER
HIERARCHICAL LEVEL
CODE
HIERARCHICAL CHILD
CODE
Y
40
RECEIVER
Y
Y
2
NON-PERSON ENTITY
Y
46
TRADING PARTNER ID
Y
Y
411674742
RECEIVER ID
Y
Y
1 THEN INCREMENT BY 1
Y
20
INFORMATION SOURCE
Y
1
STRUCTURE
BI
PXC
BILLING
CODE
C1
PRV03
NM1
CONTACT FUNCTION
CODE
NAME
COMMUNICATION
NUMBER QUALIFIER
BILLING PROVIDER SPECIALTY
INFORMATION
PRV01
PRV02
2010AA
DESCRIPTION
HIERARCHICAL LEVEL
HIERARCHICAL LEVEL
HL01
PRV
VALUE
Y
NM102
NM103
HL
REQ
Y
RECEIVER NAME
RECEIVER NAME
NM101
2000A
DHS Information
ELEMENT NAME
PROVIDER CODE
REFERENCE
IDENTIFICATION
QUALIFER
REFERENCE
IDENTIFICATION
Y
Y
Y
Y
Y
56
LOOP
SEG
NAME
ELEMENT NAME
ENTITY IDENTIFIER
CODE
REQ
Y
VALUE
85
NM102
Y
1
2
NM103
NAME LAST OR
ORGANIZATION NAME
Y
NM104
C1
NM109
BILLING PROVIDER
FIRST NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
N301
ADDRESS INFORMATION
N302
ADDRESS INFORMATION
C1
Y
N401
CITY NAME
Y
N402
STATE OR PROVINCE
CODE
POSTAL CODE
C1
NM108
N3
N4
BILLING
PROVIDERCITY/STATE/ZIP
N403
REF
IDENTIFICATION
REF02
HL
REFERENCE
IDENTIFICATION
QUALIFIER
REFERENCE
IDENTIFICATION
LEVEL
HIERARCHICAL LEVEL
XX
C1
Y
Y
NPI
PROVIDER NPI
NAME
PROVINCE CODE
POSTAL ZONE OR ZIP CODE
C1
Y
Y
EI
EMPLOYER’S IDENTIFICATION NUMBER
Y
HL01
C1
DESCRIPTION
BILLING PROVIDER
guide.
PAY TO PROVIDER
PERSON
NON-PERSON ENTITY
PROVIDER LAST OR ORGANIZATIONAL
NAME
BILLING PROVIDER FIRST NAME
Y
REF01
2000B
DHS Information
ID
NM101
HIERARCHICAL ID
NUMBER
Y
Y
57
LOOP
SEG
NAME
ELEMENT NAME
HIERARCHICAL PARENT
ID
REQ
Y
VALUE
HL03
HIERARCHICAL LEVEL
CODE
HIERARCHICAL CHILD
CODE
Y
22
Y
0
NO ADDITIONAL HL SEGMENT IN THIS
Y
Y
U
UNKNOWN
Y
18
SELF
Y
MC
MEDICAID
Y
IL
Y
Y
1
PERSON
MEMBER LAST NAME
HL04
SBR
SBR01
SBR02
SBR09
2010BA
NM1
NM104
NM105
NM108
NM109
ENTITY IDENTIFIER
CODE
NAME LAST OR
ORGANIZATION NAME
NAME FIRST
NAME MIDDLE
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
SUBSCRIBER ADDRESS
Y
C1
Y
Y
C2
N301
ADDRESS INFORMATION
SUBSCRIBER CITY, STATE, ZIP
DESCRIPTION
PROVIDER HL01 VALUE WHEN
PROVIDER NUMBER CHANGES IN A
TRANSACTION SET.
INFORMATION SOURCE
Y
NM102
NM103
N4
SEQUENCE NUMBER
CODE
INDIVIDUAL
RELATIONSHIP CODE
CLAIM FILING
INDICATOR CODE
SUBSCRIBER NAME
SUBSCRIBER NAME
NM101
N3
DHS Information
ID
HL02
Y
C2
N401
CITY NAME
Y
N402
STATE OR PROVINCE
CODE
Y
MI
MEMBER FIRST NAME
MEMBER MIDDLE INITIAL, IF KNOWN
MEMBER ID NUMBER
DHS ASSIGNED EIGHT DIGIT MEMBER
ID
58
LOOP
SEG
NAME
DMG
ID
N403
ELEMENT NAME
POSTAL CODE
DMG01
DATE TIME PERIOD
FORMAT QUALIFIER
DATE TIME PERIOD
GENDER CODE
DMG02
DMG03
REF
SUBSCRIBER SECONDARY
IDENTIFICATION
REF02
REFERENCE
IDENTIFICATION
QUALIFIER
REFERENCE
IDENTIFICATION
PAYER NAME
NM101
NM102
NM103
NM108
NM109
REF
REF02
CLM
ENTITY IDENTIFIER
CODE
NAME LAST OR
ORGANIZATION NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
BILLING PROVIDER
REF01
2300
REFERENCE
IDENTIFICATION
QUALIFIER
REFERENCE
IDENTIFICATION
CLAIM INFORMATION
CLAIM INFORMATION
CLM01
Y
Y
VALUE
DESCRIPTION
DEFAULT TO “00000”.
D8
F
M
U
FEMALE
MALE
UNKNOWN
Y4
AGENCY CLAIM NUMBER
Y
REF01
2010BB
DHS Information
REQ
Y
Y
Y
CLAIM SUBMITTER’S
IDENTIFIER
Y
Y
Y
Y
MCO’S OWN MEMBER ID
PR
PAYER
Y
Y
2
NON-PERSON ENTITY
Y
PI
PAYER ID
Y
C1
411674742
DHS PAYER ID
Y
G2
Y
UMPI)
Y
Y
Y
59
LOOP
SEG
NAME
ELEMENT NAME
MONETARY AMOUNT
REQ
Y
CLM05
HEALTH CARE SERVICE
LOCATION
INFORMATION
FACILITY CODE VALUE
FACILITY CODE
QUALIFIER
Y
Y
Y
B
CLAIM FREQUENCY
TYPE CODE (CLAIM
SUBMISSION REASON
CODE)
Y
1
PLACE OF SERVICE CODE
PLACE OF SERVICE CODES FOR
PROFESSIONAL OR DENTAL
SERVICES.
ORIGINAL
7
8
Y
REPLACEMENT
VOID
YES (DEFAULT)
N
NO
PROVIDER ASSIGNMENT CODE
Y
Y
Y
A
C
P
Y
Y
ASSIGNED
NOT ASSIGNED
PATIENT REFUSES TO ASSIGN
BENEFITS
YES (DEFAULT)
Y
N
W
Y
NO
NO APPLICABLE
YES (DEFAULT)
CLM05-1
CLM05-2
CLM05-3
CLM06
YES/NO CONDITION
RESPONSE CODE
(PROVIDER SIGNATURE
ON FILE CODE)
Y
CLM07
PROVIDER ACCEPT
ASSIGNMENT CODE
Y
CLM08
CLM09
DHS Information
ID
CLM02
YES/NO CONDITION
RESPONSE CODE
(ASSIGNMENT OF
BENEFITS CODE)
RELEASE OF
INFORMATION CODE
(RELEASE OF
INFORMATION CODE)
VALUE
DESCRIPTION
BILLED AMOUNT. PER APPENDIX A IN
THE IMPLEMENTATION GUIDE,
DECIMAL DATA ELEMENTS IN DATA
ELEMENT 782 WILL BE LIMITED TO A
MAXIMUM LENGTH OF 10
60
LOOP
SEG
NAME
ID
CLM11
CLM11-1
TO
CLM11-3
DTP
DTP03
DTP
DTP03
DTP03
REF
C1
DATE/TIME QUALIFIER
DATE TIME PERIOD
FORMAT QUALIFIER
DATE TIME PERIOD
DATE/TIME QUALIFIER
DATE TIME PERIOD
FORMAT QUALIFIER
DATE TIME PERIOD
DATE- SERVICE
DTP01
DTP02
AMT
RELATED CAUSES
INFORMATION
RELATED CAUSES CODE
DATE- APPLIANCE PLACEMENT
DTP01
DTP02
DTP
REQ
DATE-ACCIDENT
DTP01
DTP02
DATE/TIME QUALIFIER
DATE TIME PERIOD
FORMAT QUALIFIER
DATE TIME PERIOD
PATIENT AMOUNT PAID
PAYER CLAIM CONTROL
NUMBER (ICN/DCN)
DHS Information
ELEMENT NAME
VALUE
I
DESCRIPTION
INFORMED CONSENT
AA
AUTO ACCIDENT
EM
OA
EMPLOYMENT
OTHER ACCIDENT
C1
C1
C1
439
D8
C1
C1
Y
Y
ACCIDENT
CCYYMMDD
ACCIDENT DATE
452
D8
Y
C1
Y
Y
APPLIANCE PLACEMENT
CCYYMMDD
APPLIANCE PLACEMENT DATE
472
D8
SERVICE DATE(S)
CCYYMMDD
DATES OF SERVICE
INFORMATION IS SENT IN THIS
SEGMENT WHETHER THE PAYMENT IS
FROM THE PATIENT OR THE
PROVIDER.
PATIENT AMOUNT PAID. ENTER IF
APPLICABLE
C1
Y
C1
AMT01
AMOUNT QUALIFIER
CODE
Y
AMT02
MONETARY AMOUNT
Y
F5
ENTER TOTAL TPL AND/OR MEDICARE
PAYMENT, IF APPLICABLE. PER
DATA ELEMENT 782 WILL BE LIMITED
TO A MAXIMUM LENGTH OF 10
C1
61
LOOP
SEG
NAME
ID
REF01
REF02
HI
CODES
HI01-1
HEALTH CARE CODE
INFORMATION
CODE LIST QUALIFIER
CODE
DESCRIPTION
PAYER CLAIM CONTROL NUMBER
USED WHEN CLM05-3 IS 7REPLACEMENT OR 8-VOID. THIS IS
FOR REPLACEMENT CLAIM OR VOID
CLAIM USAGE ONLY.
Y
Y
INDUSTRY CODE
HEALTH CARE CODE
INFORMATION
Y
C1
CODE LIST QUALIFIER
CODE(S)
Y
HI02-2
THRU
HI04-2
INDUSTRY CODE
Y
BK
DIAGNOSIS CODE.
ABK
BF
ABF
DIAGNOSIS CODE
82
RENDERING PROVIDER
1
2
PERSON
NON-PERSON
C1
NM101
NM102
NM103
NM104
VALUE
F8
Y
HI01-2
HI02
THRU
HI04
HI02-1
THRU
HI04-1
NM1
DHS Information
REQ
Y
C1
HI01
2310B
ELEMENT NAME
REFERENCE
IDENTIFICATION
QUALIFIER
REFERENCE
IDENTIFICATION
ENTITY IDENTIFIER
CODE
Y
Y
Y
NAME LAST OR
ORGANIZATION NAME
Y
NAME FIRST
C1
DEFAULT TO ANY TEXT- NOT USED
BUT REQUIRED BY STANDARD.
62
LOOP
SEG
PRV
NAME
ID
NM108
REQ
Y
NM109
PRV01
PROVIDER CODE
Y
PE
PERFORMING
PRV02
REFERENCE
IDENTIFICATION
QUALIFIER
PROVIDER TAXONOMY
CODE
Y
PXC
CODE
RENDERING PROVIDER
SPECIALITY INFORMATION
PRV03
REF
REF01
REF02
2310C
NM1
Y
Y
RENDERING PROVIDER NPI NUMBER
RENDERING PROVIDER TAXONOMY
CODE INFORMATION
Y
C2
Y
DESCRIPTION
NPI
TAXONOMY CODE. DEFAULT
TAXONOMY CODE = “777A00000Z”
G2
(FOR UMPI NUMBERS)
DHS UMPI NUMBER
NAME
C1
THAN THAT CARRIED IN LOOP 2010AA.
NAME
C1
NM102
NM103
NM108
NM109
N4
REFERENCE
IDENTIFICATION
QUALIFIER
REFERENCE
IDENTIFICATION
VALUE
XX
Y
NM101
N3
DHS Information
ELEMENT NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
ENTITY IDENTIFIER
CODE
NAME LAST OR
ORGANIZATION NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
ADDRESS
Y
77
SERVICE LOCATION
Y
Y
2
NON-PERSON ENTITY
C1
XX
NPI
C1
IDENTIFIER
Y
N301
ADDRESS INFORMATION
Y
N302
ADDRESS INFORMATION
C1
LINE
LINE
Y
63
LOOP
SEG
NAME
ELEMENT NAME
CITY NAME
REQ
Y
N402
STATE OR PROVINCE
CODE
POSTAL CODE
C1
N403
REF
REF02
NM1
REFERENCE
IDENTIFICATION
QUALIFIER
REFERENCE
IDENTIFICATION
SUPERVISING PROVIDER
NAME
NAME
DESCRIPTION
LABORATORY OR FACILITY CITY
NAME
PROVINCE CODE
ZONE OR ZIP CODE
G2
(FOR UMPI NUMBERS)
C1
Y
Y
LABORATORY OR FACILITY
SECONDARY IDENTIFIER (DHS UMPI
NUMBER)
C1
Y
NM101
NM102
NM103
NM108
NM109
REF
VALUE
C1
REF01
2310E
DHS Information
ID
N401
ENTITY ID CODE
NAME LAST/ORG NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
Y
Y
Y
Y
DQ
1
XX
Y
PERSON
SUPERVISING PROVIDER LAST NAME
SUPERVISING PROVIDER IDENTIFIER
(NPI)
C1
SUPERVISION PROVIDER SECONDARY
IDENTIFIER
REF01
REF02
REFERENCE
IDENTIFICATION
QUALIFIER
REFERENCE
IDENTIFICATION
Y
Y
G2
(FOR UMPI NUMBERS)
DHS UMPI NUMBER
64
LOOP
2320
SEG
NAME
OTHER SUBSCRIBER
INFORMATION
SBR
OTHER SUBSCRIBER
INFORMATION
ID
ELEMENT NAME
DHS Information
REQ
C2
VALUE
DESCRIPTION
THIS LOOP IS REQUIRED - THE FIRST
OCCURRENCE MUST CONTAIN
INFORMATION FOR THE MCO AS THE
PRIMARY/SECONDARY PAYER. IF THE
PRIMARY PAYER IS A THIRD PARTY,
THE SECOND OCCURRENCE OF THIS
SEGMENT SHOULD CONTAIN A “P”
AND INFORMATION RELATED TO THE
RELEVANT THIRD PARTY PAYER. UP
TO 10 SBR LOOPS CAN BE SENT.
Y
P
PRIMARY
SECONDARY
TERTIARY
GUIDE FOR THE OTHER
CODES/VALUES
Y
S
T
SEE X12
IG FOR
ADDT’L
CODES/
VALUES
18
Y
SBR01
SBR02
SEQUENCE NUMBER
CODE
INDIVIDUAL
RELATIONSHIP CODE
SEE X12
IG FOR
ADDT’L
CODES/
VALUES
SBR03
SBR05
SBR09
REFERENCE
IDENTIFICATION
INSURANCE TYPE CODE
C1
CLAIM FILING
INDICATOR CODE
Y
C1
SEE X12
IG FOR
ADDT’L
CODES/
VALUES
HM
11
occurrence. Subsequent occurrences
should be billed as appropriate.
GUIDE FOR THE OTHER
CODES/VALUES
INSURANCE GROUP OR POLICY
NUMBER
REQUIRED WHEN MEDICARE PRESENT
AND MEDICARE IS NOT PRIMARY
PAYER.
HEALTH MAINTENANCE
ORGANIZATION (HM) – This is only for
the first occurrence. On subsequent
occurrences, fill out as appropriate.
65
LOOP
SEG
CAS
NAME
ID
ELEMENT NAME
DHS Information
REQ
VALUE
SEE X12
IG FOR
ADDT’L
CODES/
VALUES
C1
CAS01
CLAIM ADJUSTMENT
GROUP CODE
Y
CO
CR
OA
PI
PR
CAS02
CAS03
CAS04
CAS05
CAS06
CAS07
CAS08
CAS09
CAS10
CAS11
CAS12
CAS13
CAS14
CAS15
CAS16
CAS17
CAS18
CAS19
AMT
CLAIM ADJUSTMENT
REASON CODE
MONETARY AMOUNT
QUANTITY
CLAIM ADJUSTMENT
REASON CODE
MONETARY AMOUNT
QUANTITY
CLAIM ADJUSTMENT
REASON CODE
MONETARY AMOUNT
QUANTITY
CLAIM ADJUSTMENT
REASON CODE
MONETARY AMOUNT
QUANTITY
CLAIM ADJUSTMENT
REASON CODE
MONETARY AMOUNT
QUANTITY
CLAIM ADJUSTMENT
REASON CODE
MONETARY AMOUNT
QUANTITY
AMT01
AMOUNT QUALIFIER
CODE
DESCRIPTION
GUIDE FOR THE OTHER
CODES/VALUES
ADJUSTMENTS
Y
OTHER ADJUSTMENTS
ADJUSTMENT REASON
Y
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
ADJUSTMENT REASON
C1
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
ADJUSTMENT REASON
C1
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
ADJUSTMENT REASON
C1
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
ADJUSTMENT REASON
C1
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
ADJUSTMENT REASON
C1
C1
C2
Y
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
D
PAYOR PAID AMOUNT
66
LOOP
SEG
NAME
AMT
ID
AMT02
ELEMENT NAME
MONETARY AMOUNT
AMT01
AMOUNT QUALIFIER
CODE
MONETARY AMOUNT
AMT02
AMT
AMOUNT
AMT01
AMT02
OI
OI06
2330A
Y
C1
Y
Y
Y
Y
NM101
NM102
ENTITY ID CODE
NM103
NAME LAST OR
ORGANIZATION NAME
NAME FIRST
NAME MIDDLE
NAME SUFFIX
ID CODE QUALIFIER
ID CODE
OTHER PAYER NAME
NM101
NM102
AMOUNT OWED
YES/NO CONDITION OR
RESPONSE
RELEASE OF
INFORMATION
OTHER PAYER NAME
NM1
EAF
A8
Y
Y
ENTITY IDENTIFIER
CODE
Y
Y
Y
Y
C1
C1
C1
Y
Y
C2
C1
NM104
NM105
NM107
NM108
NM109
2330B
DESCRIPTION
PAYER PAID AMOUNT; ZERO IS
ACCEPTABLE
Y
NM1
C1
Y
VALUE
AMOUNT QUALIFIER
CODE
MONETARY AMOUNT
OTHER INSURANCE
COVERAGE INFORMATION
OI03
DHS Information
REQ
Y
ONE SUBSCRIBER NAME PER SBR
SEGMENT.
IL
1
2
UNKNOWN
PERSON
NON-PERSON ENTITY
MI
UNKNOWN
THIS LOOP IS REQUIRED – MCO
ADJUDICATION INFORMATION AS A
PAYER IS SUBMITTED HERE AND TPL
ADJUDICATION INFORMATION, ONE
OTHER PAYER NAME PER SBR
SEGMENT.
Y
Y
PR
PAYER
Y
2
NON-PERSON ENTITY
67
LOOP
SEG
NAME
ID
NM103
NM108
NM109
DTP
CLAIM CHECK OR
REMITTANCE DATE
DTP03
REF02
LX
SV3
DESCRIPTION
Y
PI
Y
Y
Y
REFERENCE
IDENTIFICATION
QUALIFIER
REFERENCE
IDENTIFICATION
Y
SERVICE LINE
LINE NUMBER
LX01
ASSIGNED NUMBER
SV301
COMPOSITE MEDICAL
PRODUCT SERVICE ID
QUALIFIER
PRODUCT/SERVICE ID
PROCEDURE MODIFIER
PROCEDURE MODIFIER
PROCEDURE MODIFIER
PROCEDURE MODIFIER
DENTAL SERVICE
SV301-1
SV301-2
SV301-3
SV301-4
SV301-5
SV301-6
VALUE
UNKNOWN
DATE/TIME QUALIFIER
DATE TIME PERIOD
FORMAT QUALIFIER
DATE TIME PERIOD
OTHER PAYER CLAIM
CONTROL NUMBER
REF01
2400
DHS Information
REQ
Y
C1
DTP01
DTP02
REF
ELEMENT NAME
NAME LAST OR
ORGANIZATION NAME
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
573
D8
DATE CLAIM PAID
F8
MUST BE USED FOR MEDICARE
CLAIMS.
Y
C1
Y
OTHER PAYER’S CLAIM CONTROL
NUMBER
Y
Y
Y
BEGINS WITH 1 AND INCREMENTED BY
1
Y
Y
Y
Y
C1
C1
C1
C1
AD
ADA PROCEDURE
ADA PROCEDURE CODE
MODIFIER 1
MODIFIER 2
MODIFIER 3
MODIFIER 4
68
LOOP
SEG
NAME
ELEMENT NAME
MONETARY AMOUNT
REQ
Y
SV303
FACILITY CODE VALUE
Y
SV304
ORAL CAVITY
DESIGNATION
ORAL CAVITY
DESIGNATION CODE
C1
SV304-1
SV305
SV306
SV311-1
SV311-2
THRU
SV311-4
TOO
PROSTHESIS, CROWN
OR INLAY CODE
QUANTITY
DIAGNOSIS CODE
POINTER
DIAGNOSIS CODE
POINTER
TOOTH INFORMATION
VALUE
DESCRIPTION
DATA ELEMENT 782 WILL BE LIMITED
TO A MAXIMUM LENGTH OF 10
OVERRIDE CLM05-1 IN LOOP 2300
WHEN PLACE OF SERVICE IS
DIFFERENT THAN THE VALUE SENT AT
THE CLAIM LEVEL.
Y
10
UPPER RIGHT QUADRANT
C1
20
30
40
I
UPPER LEFT QUADRANT
LOWER LEFT QUADRANT
LOWER RIGHT QUADRANT
INITIAL
R
Y
Y
REPLACEMENT
UNITS OF SERVICE
PRIMARY DIAGNOSIS CODE POINTER
C1
C1
TOO01
TOO02
TOO03
TOO03-1
DHS Information
ID
SV302
CODE LIST QUALIFIER
CODE
INDUSTRY CODE
TOOTH SURFACE
TOOTH SURFACE CODE
Y
Y
C1
Y
JP
NATIONAL STANDARD TOOTH NUMBER
TOOTH NUMBER
B
D
F
I
L
M
O
BUCCAL
DISTAL
FACIAL
INCISAL
LINGUAL
MESIAL
OCCLUSAL
69
LOOP
SEG
DTP
DTP
DTP
REF
NAME
ELEMENT NAME
TOOTH SURFACE CODE
REQ
C1
TOO03-3
TOOTH SURFACE CODE
C1
TOO03-4
TOOTH SURFACE CODE
C1
TOO03-5
TOOTH SURFACE CODE
C1
DTP01
DTP02
DATE/TIME QUALIFIER
DATE TIME PERIOD
FORMAT QUALIFIER
DATE – SERVICE DATE
C1
Y
Y
DTP03
DATE TIME PERIOD
DTP01
DTP02
DATE/TIME QUALIFIER
DATE TIME PERIOD
FORMAT QUALIFIER
DTP03
DATE TIME PERIOD
Y
C2
DTP01
DTP02
DATE/TIME QUALIFIER
DATE TIME PERIOD
FORMAT QUALIFIER
Y
Y
DTP03
DATE TIME PERIOD
Y
C1
REF01
REFERENCE
IDENTIFICATION
QUALIFIER
DATE- PRIOR PLACEMENT
DATE- REPLACEMENT
LINE ITEM CONTROL NUMBER
DHS Information
ID
TOO03-2
Y
C1
Y
Y
VALUE
REPEAT
OF
VALUES
ABOVE
REPEAT
OF
VALUES
ABOVE
REPEAT
OF
VALUES
ABOVE
REPEAT
OF
VALUES
ABOVE
DESCRIPTION
REPEAT OF VALUES ABOVE
472
D8
SERVICE DATE(S)
CCYYMMDD
RD8
CCYYMMDD-CCYYMMDD
SERVICE DATE
441
D8
PRIOR PLACEMENT
CCYYMMDD
PRIOR PLACEMENT DATE
MCO PAID DATE
446
D8
PAID DATE
CCYYMMDD
DATE OF PAYMENT TO THE PROVIDER
6R
LINE ITEM CONTROL NUMBER
70
LOOP
SEG
REF
NAME
ID
REF02
ELEMENT NAME
REFERENCE
IDENTIFICATION
REF01
REFERENCE
IDENTIFICATION
QUALIFIER
REFERENCE
IDENTIFICATION
REPRICED CLAIM NUMBER
REF02
REF
ADJUSTED REPRICED CLAIM
NUMBER
REF02
REFERENCE
IDENTIFICATION
QUALIFIER
REFERENCE
IDENTIFICATION
NM1
C2
Y
VALUE
DESCRIPTION
MCO’S LINE ITEM CONTROL NUMBER
9A
PAID AMOUNT
Y
PAID AMOUNT IS THE AMOUNT PAID
TO THE PROVIDER EXCLUDING THIRD
WITHHOLDS, INCENTIVES AND
MEMBER COST SHARING SEE
APPENDIX – P. 77
C2
REF01
2420A
DHS Information
REQ
C1
Y
9C
Y
ALLOWED AMOUNT
ALLOWED AMOUNT IS DEFINED AS THE
PROVIDER CONTRACTED RATE PRIOR
TO ANY EXCLUSIONS OR ADD ONS.
SEE APPENDIX – P. 77
OVERRIDE 2310B LOOP IF THE
RENDERING PROVIDER ON A LINE
ITEM IS DIFFERENT THAN THE
NUMBER SUBMITTED AT THE CLAIM
LEVEL.
C1
NM101
NM102
NM103
NM104
NM108
NM109
ENTITY IDENTIFIER
CODE
Y
82
RENDERING PROVIDER
Y
1
2
NAME LAST OR
ORGANIZATION NAME
NAME FIRST
Y
PERSON
NON-PERSON
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
C1
Y
Y
XX
ANY TEXT- REQUIRED IF “1” IS SENT IN
NM102.
NPI
RENDERING PROVIDER NPI NUMBER IF
XX
71
LOOP
2420A
SEG
NAME
RENDERING PROVIDER
SPECIALITY INFORMAITON
ID
REQ
Y
VALUE
DESCRIPTION
RENDERING PROVIDER TAXONOMY
CODE INFORMATION
PRV01
PROVIDER CODE
Y
PE
PERFORMING
PRV02
REFERENCE
IDENTIFICATION
QUALIFIER
PROVIDER TAXONOMY
CODE
Y
PXC
CODE
PRV03
REF
REF01
REF02
2420C
DHS Information
ELEMENT NAME
REFERENCE
IDENTIFICATION
QUALIFIER
REFERENCE
IDENTIFICATION
Y
C1
Y
TAXONOMY CODE – DEFAULT TO
777A000002.
G2
Y
DHS UMPI NUMBER.
C1
OVERRIDES 2310E LOOP IF THE
SUPERVISING PROVIDER ON A LINE
ITEM IS DIFFERENT THAN THE
NUMBER SUBMITTED AT THE CLAIM
LEVEL.
NAME
NM1
NAME
Y
NM101
ENTITY ID CODE
Y
DQ
NM102
Y
1
PERSON
NM103
NAME LAST/ORG NAME
Y
NM108
IDENTIFICATION CODE
QUALIFIER
IDENTIFICATION CODE
C1
NM109
2430
LINE ADJUDICATION
INFORMATION
SVD
LINE ADJUDICATION
INFORMATION
(FOR UMPI NUMBERS)
C1
C1
SUPERVISING PROVIDER LAST NAME
XX
SUPERVISING PROVIDER IDENTIFIER
THIS LOOP IS REQUIRED. MCO
ADJUDICATION INFORMATION AS A
PAYER IS SUBMITTED HERE AND TPL
ADJUDICATION INFORMATION YOU
CAN SEND UP TO 15 OF THESE; SEND
ONE PER L2330B/NM1*PR SEGMENT.
Y
SVD01
IDENTIFICATION CODE
Y
SVD02
MONETARY AMOUNT
Y
72
LOOP
SEG
NAME
ID
SVD03
SVD03-1
SVD03-2
SVD03-3
SVD03-4
SVD03-5
SVD03-6
SVD05
CAS
ELEMENT NAME
COMPOSITE MEDICAL
PROCEDURE
PRODUCT/SERVICE ID
QUALIFIER
PRODUCT SERVICE ID
PROCEDURE MODIFIER
PROCEDURE MODIFIER
PROCEDURE MODIFIER
PROCEDURE MODIFIER
QUANTITY
LINE ADJUSTMENT
CAS01
CAS02
CAS03
CAS04
CAS05
CAS06
CAS07
CAS08
CAS09
CAS10
CAS11
CAS12
CAS13
CAS14
CAS15
CAS16
CAS17
CAS18
CAS19
CLAIM ADJUSTMENT
GROUP CODE
CLAIM ADJUSTMENT
REASON CODE
MONETARY AMOUNT
QUANTITY
CLAIM ADJUSTMENT
REASON CODE
MONETARY AMOUNT
QUANTITY
CLAIM ADJUSTMENT
REASON CODE
MONETARY AMOUNT
QUANTITY
CLAIM ADJUSTMENT
REASON CODE
MONETARY AMOUNT
QUANTITY
CLAIM ADJUSTMENT
REASON CODE
MONETARY AMOUNT
QUANTITY
CLAIM ADJUSTMENT
REASON CODE
MONETARY AMOUNT
QUANTITY
DHS Information
REQ
Y
VALUE
DESCRIPTION
Y
AD
Y
C1
C1
C1
C1
Y
C1
Y
AMERICAN DENTAL ASSOCIATION
CODES
PROCEDURE CODE
MODIFIER 1
MODIFIER 2
MODIFIER 3
MODIFIER 4
PAID SERVICE UNITS COUNT
CO
CR
OA
PI
PR
Y
OTHER ADJUSTMENTS
Y
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
Y
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
Y
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
Y
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
Y
C1
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
Y
C1
ADJUSTMENT AMOUNT
ADJUSTMENT QUANTITY
73
LOOP
SEG
DTP
NAME
ID
DTP01
DTP02
DTP03
AMT
AMT02
SE
DATE/TIME QUALIFIER
DATE TIME PERIOD
FORMAT QUALIFIER
DATE TIME PERIOD
AMT01
TRL
ELEMENT NAME
AMOUNT QUALIFIER
CODE
MONETARY AMOUNT
TRAILER
SE01
SE02
TRANSACTION
SEGMENT COUNT
TRANSACTION SET
CONROL NUMBER
DHS Information
REQ
Y
Y
Y
573
D8
Y
C1
Y
DESCRIPTION
MEDICARE OR PAYER PAID DATE
DATE CLAIM PAID
CCYYMMDD
EAF
AMOUNT OWED
Y
Y
Y
Y
VALUE
TOTAL SEGMENTS IN TRANSACTION
SET.
MUST MATCH ST02.
REFERENCE
DESCRIPTION
ISA01
ISA02
ISA03
ISA04
ISA05
ISA06
ELEMENT DESCRIPTION
AUTHORIZATION
INFORMATION QUALIFIER
AUTHORIZATION
INFORMATION
QUALIFIER
837D VALUES
DO NOT SEND SEGMENT DELIMITERS THAT ARE MORE THAN ONE BYTE. SEE APPENDIX A.1.2.4
THROUGH A.1.2.7 IN THE 837 IMPLEMENTATION GUIDE FOR LISTS OF CHARACTERS THAT ARE
ALLOWED. IF YOU SEND CHARACTERS THAT ARE NOT WITHIN THE SETS SHOWN IN THE GUIDE,
YOUR FILE WILL NOT BE PROCESSED. QUALIFIER VALUES ARE CASE SENSITIVE. IF LOWER
CASE VALUES ARE SENT, YOUR FILE WILL NOT BE PROCESSED. PLEASE SEND ONE
INTERCHANGE PER FILE UNTIL FURTHER NOTICE. IF YOU SEND MORE THAN ONE
INTERCHANGE, THE ADDITIONAL INTERCHANGES MAY NOT BE PROCESSED.
00-NO AUTHORIZATION INFORMATION PRESENT.
10 SPACES
10 SPACES
INTERCHANGE ID QUALIFIER ZZ-MUTUALLY DEFINED
CORRESPOND TO THE MN-ITS MAILBOX NUMBER. THIS MUST CHANGE TO THE 10-DIGIT
NATIONAL PROVIDER IDENTIFIER (NPI) OR UNIVERSAL MINNESOTA PROVIDER IDENTIFIER (UMPI)
74
FOLLOWED BY 5 TRAILING SPACES.
ISA07
ISA08
ISA09
ISA10
INTERCHANGE ID QUALIFIER 30-U.S. FEDERAL TAX IDENTIFICATION NUMBER
INTERCHANGE RECEIVER ID 41-1674742-MN DEPT OF HUMAN SERVICES FEIN FOLLOWED BY 5 TRAILING SPACES. THIS
NUMBER MUST CONTAIN A HYPHEN.
INTERCHANGE DATE
INTERCHANGE TIME
ISA11
ISA12
INTERCHANGE CONTROL
VERSION NUMBER
INTERCHANGE CONTROL
NUMBER
ACKNOWLEDGMENT
REQUESTED
USAGE INDICATOR
COMPONENT ELEMENT
SEPARATOR
ISA13
ISA14
ISA15
ISA16
BEGIN WITH "1" 9-DIGIT ZERO FILLED LEFT TO RIGHT. ALL ZEROS IS NOT AN ALLOWED VALUE.
REFERENCE
DESCRIPTION
ELEMENT DESCRIPTION
837D VALUES
IEA01
NUMBER OF INCLUDED FUNCTIONAL PROVIDER TRANSLATOR COUNTS NUMBER OF FUNCTIONAL GROUPS WITHIN THE
GROUPS
INTERCHANGE.
IEA02
SAME AS ISA13
REFERENCE
ELEMENT DESCRIPTION
DESCRIPTION
GS01
GS02
GS03
GS04
GS05
FUNCTIONAL GROUP CREATION
DATE
CREATION TIME
837D VALUES
PROVIDER IDENTIFIOER (UMPI). MUST MATCH THE NUMBER IN ISA06 WITHOUT THE TRAILING
SPACES.
75
GS06
GS07
GS08
IDENTIFIER CODE
UNIQUE 1-DIGIT TO 9-DIGIT NUMBER. PREFERABLY START AT 1 AND INCREMENT BY 1 FOR
EACH SUCCESSIVE FUNCTIONAL GROUP FROM SENDER TO RECEIVER, AND NOT RESET TO
STARTING VALUE OF 1 WITHIN EACH INTERCHANGE OR EACH DAY.
005010X224A2-DRAFT STANDARDS APPROVED BY ASC X12 BOARD.
REFERENCE
ELEMENT DESCRIPTION
DESCRIPTION
GE01
INCLUDED
GE02
837D VALUES
FUNCTIONAL GROUP.
76
APPENDIX – PAID AMOUNT AND ALLOWED AMOUNT RULES
•
•
•
•
•
•
•
•
•
•
•
Include decimal in the value, so it represents dollars and cents: xx.xx
Do not include commas
0.00 is valid, but a negative number is not
Submit paid amount only on the CPT/HCPCS code line for which payment was determined or made. Submit this amount only once.
All other lines within the same claim where payment is inclusive of another line should be sent with 0.00 in the paid amount
Do not repeat the paid amount on every line within the claim
All subsequent claims that are part of a package payment, where no additional payment is made (e.g., a global or surgical claim),
submit 0.00 in the paid amount
For any claim services that are payable outside of the global CPT/HCPCS code (e.g. physician-administered drugs), submit the paid
amounts on the related line
Capitated services should be submitted if they are calculated and go through the claim system, by line or on one line as is
appropriate
837P –individual paid amounts are at line level
837I – claim total paid is on the header; individual paid amounts are at line level, according to the level at which payment was
made. For example, if an inpatient claim is paid according to a DRG, the amount is at the header. If there are additional procedures
which are paid on the claim, those are on lines. The total paid for the DRG and any additional payments is on the header. A
different example is inpatient CD residential treatment, which is paid at the line. The total paid for the claim is put on the header.
77

MINNESOTA HEALTH CARE PROGRAMS Professional, Institutional, and Dental Claims

Transcription

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