Purpose of the 837 Health Care Claim: Professional

Transcription

1 Oklahoma Medicaid Management Information System Interface Specifications 837 Professional Health Care Claim HIPAA Guidelines for Electronic Transactions Companion Document The following is intended to be a companion document to the National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Claim: Professional, ASC X12N 837 (004010X098A1). The specifications in this document are clarifications that are allowed within the HIPAA transaction sets. The Oklahoma Medicaid Management Information System will only accept data in this transaction that is allowed by the HIPAA rules and guides. This document does not outline all data segments and elements that are in the HIPAA transaction set guide. This document will only clarify segments as they apply to the Oklahoma Medicaid Management Information System. Additional information on the Final Rule for Standards for Electronic Transmissions can be found at The HIPAA Implementation Guides can be accessed at Purpose of the 837 Health Care Claim: Professional The 837 Professional Transaction is the format used to electronically submit professional health care claims and encounter data to a payer for payment. The intent is to expedite the goal of achieving a totally electronic data interchange environment for health care encounters/claims processing and payment. This transaction will support the submission of professional claims, professional encounters and Coordination of Benefits for Medicare Part B. The 837 Professional Transaction is the electronic equivalent of the paper HCFA-1500 claim form; therefore, any claim types or encounter data submitted on the HCFA-1500 form correlate to the 837 Professional when the data is submitted electronically. The 837 Professional Transaction is the only acceptable format for electronic professional claim submission to the Oklahoma MMIS. All required segments within the 837 Professional Transaction set must be sent by the submitter and received by the payer. Optional information will be sent when it is necessary for processing. Segments that are conditional are only sent when special criteria is met. It is anticipated that professional claims and encounter data will be submitted from Medicaid providers, billing services, clearinghouses, value added networks (VAN), and Medicare intermediaries/carriers. Revised 5/23/2007 Page 1 of 16

2 Special Notes Applicable to Entire Transaction Syntax: Always use a tilde ( ~ ) as the segment terminator, an asterisk ( * ) as the element separator and a colon ( : ) as the sub-element separator. Alpha characters should always be submitted in ALL CAPS. To insure proper claims adjudication, zip codes must be ALL NUMERIC NINE DIGITS with no punctuation or blanks in the field. Syntax: Always use a tilde ( ~ ) as the segment terminator, an asterisk ( * ) as the element separator and a colon ( : ) as the sub-element separator. Alpha characters should always be submitted in ALL CAPS. Zip codes must be all numeric five to nine characters with no punctuation or blanks in the field. Subscriber, Insured, and Member = Client in the Oklahoma Medicaid Environment The State of Oklahoma's Medicaid Agency enrolls all members as a primary subscriber within each program. Provider Identification = National Provider Identifier (NPI) During the March 19, May 22, 2008 Dual Use Period, the State of Oklahoma s Medicaid Agency will accept the National Provider Identifier (NPI), but will continue to require the Oklahoma Health Care Authority-assigned 10- character Provider for claims adjudication. Beginning May 23, 2008, the National Provider Identifier must be used as the primary identifier for all healthcare providers. In the 837 Professional transaction, this identifier will be sent in the NM109 data element in the following loops: 2010AA, 2010AB, 2310A, 2310B, 2310C, 2310D, 2310E, 2420A, 2420B, 2420C, 2420D, 2420E and 2420F*. During the Dual Use Period, the tax number formerly used as the primary identifier in the 2010AA and 2010AB loops must be sent in the REF segment of those loops with either an EI or SY qualifier (for Employer s Identification Number or Social Security Number, respectively). Also, during the Dual Use period, REF segments with the 1D qualifier followed by the 10-character Oklahoma Medicaid Provider previously assigned by the Oklahoma Health Care Authority must still be sent in order for claims to be properly adjudicated. * PLEASE NOTE: Not all of the loops referenced will be present on every transaction. Revised 5/23/2007 Page 2 of 16

3 Provider Identification = Oklahoma Medicaid Provider The State of Oklahoma's Medicaid Agency will accept the National Provider Identifier (NPI), but will continue to require the Oklahoma Health Care Authority-assigned 10-character Provider for claims adjudication until further notice from OHCA. Oklahoma Medicaid Health Plan = OHCA Federal Tax The State of Oklahoma's Medicaid Agency uses the Oklahoma Health Care Authority s Federal Tax in all instances requiring a Health Plan. When the National Health Plan Identifier (NPlan) is approved and available, that number will be used. Revised 5/23/2007 Page 3 of 16

4 837 Professional Transaction Set Companion Document Header 837 Professional Element Segment Loop Interchange Control Header ISA01 Authorization Information ISA N/A 00 (zero zero) No Authorization Information Present (No 00 meaningful information in ISA02) ISA02 Authorization Information ISA N/A Blank (Fill with 10 spaces) ISA03 Security Information ISA N/A 00 (zero zero) No Security Information Present (No 00 meaningful information in ISA04) ISA04 Security Information ISA N/A Blank (Fill with 10 spaces) ISA05 Interchange ISA N/A ZZ (for Mutually Defined) ZZ ISA06 Interchange Sender ISA N/A 10-character Provider assigned by OHCA or 9-digit Billing A Agent assigned by EDS (either must be left-justified, with the remainder of 15-byte field space-filled). ISA06 value also appears in GS02. ISA07 Interchange ISA N/A ZZ (for Mutually Defined) ZZ ISA08 Interchange Receiver ISA N/A OHCA Tax Number (left-justified) Remaining six digits of 15-byte field must be space-filled. ISA08 value also appears in GS03. ISA09 Interchange Date ISA N/A Interchange Creation Date in YYMMDD format ISA10 Interchange Time ISA N/A Interchange Creation Time in HHMM format 0941 ISA11 Interchange Control ISA N/A U (for U.S. EDI Community of ASC X12, TDCC and UCS) U Standards Identifier ISA12 Interchange Control Version Number ISA N/A ISA13 Interchange Control Number ISA N/A Unique number that should start with 1 and increment by 1 with each ISA record submitted. The number should be 9 characters and be identical to the value in IEA Revised 5/23/2007 Page 4 of 16

5 ISA14 Acknowledgment Requested Segment Loop ISA N/A 1 (for Interchange Acknowledgment Requested) 1 ISA15 Usage Indicator ISA N/A P (for Production Data) P T (for Test Data) ISA16 Component Element Separator ISA N/A A : (colon) must be sent in this field. : Functional Group Header GS01 Functional Identifier GS N/A HC (for Health Care Claim 837) HC GS02 Application Sender s GS N/A 10-character Provider assigned by OHCA or 9-digit Billing Agent assigned by EDS (Same value as ISA06) A GS03 Application Receiver s GS N/A OHCA Tax Number (Same value as ISA08) GS04 Date GS N/A Functional Group Creation Date in CCYYMMDD format GS05 Time GS N/A Functional Group Creation Time in HHMM format 0941 GS06 Group Control Number GS N/A Unique number within interchange. Will begin with 0001 and will increment by 1 with each ISA sent, and will be identical to GE02. GS07 Responsible Agency GS N/A X (from Accredited Standards Committee X12) X GS08 Version/Release/Industry Identifier GS N/A X098A X098A1 Transaction Set Header Indicates the start of the Transaction Set ST01 Transaction Set Identifier ST N/A 837 (for Health Care Claim) 837 ST02 Transaction Set Control Number ST N/A Unique number to the interchange that must be identical to value 0001 in SE02 Beginning of Hierarchical Transaction First segment of the 837 Professional Transaction Set BHT01 Hierarchical Structure BHT N/A 0019 (for Information Source, Subscriber, Dependent) 0019 BHT02 Transaction Set Purpose BHT N/A 00 (for Original) 00 REF01 Reference Identification REF N/A 87 (for Functional Category) 87 Revised 5/23/2007 Page 5 of

6 Segment Loop REF02 Reference Identification REF N/A X098A X098A1 Transmission Type NM109 Submitter Identifier NM1 1000A 10-character Provider assigned by OHCA or 9-digit Billing Agent assigned by EDS A PER01 Contact Function PER 1000A IC (for Information Contact) IC PER02 Submitter Contact Name PER 1000A Name of person submitting claim JANE DOE PER03 Communication Number PER 1000A TE (for Telephone) or FX (for Fax) TE PER04 Communication Number PER 1000A Telephone or Fax Number NM103 Receiver or Organization Name NM1 1000B OKLAHOMA HEALTH CARE AUTHORITY OKLAHOMA HEALTH CARE AUTHORITY NM109 Receiver Primary NM1 1000B OHCA Tax Number HL01 Identification Number Billing/Pay-to Provider Hierarchical Number HL 2000A HL01 must begin with a 1 and increase by 1 each time HL is used. Only numeric values are allowed in HL01. HL03 Hierarchical Level HL 2000A 20 (for Information Source) HL*1**20 HL04 Hierarchical Child HL 2000A 1 (to indicate that subordinate HL segments will follow) HL*1**20*1 The 2000A-PRV-Billing/Pay-to Provider Specialty Information segment is required when the provider taxonomy code affects the adjudication of the claim and the Billing/Pay-to Provider and the Rendering Provider are the same entity. In this event, the 2310B-Rendering Provider loop is not used. If the Billing/Pay-to Provider is a group and the Rendering Provider is an individual, the 2310B-Rendering Provider loop is used and the PRV segment at that loop is populated with the Rendering Provider taxonomy code information. PRV01 Provider PRV 2000A BI (for Billing Provider) BI PT (for Pay-to Provider) PRV02 Reference Identification PRV 2000A ZZ (for Mutually Defined) ZZ PRV03 Billing/Pay-To Provider Specialty Information PRV 2000A The Health Care Provider Taxonomy (Provider Specialty ), available at the Washington Publishing Company Internet website: Revised 5/23/2007 Page 6 of 16 HL*1 208D00000X The 2010AA-NM1 Billing Provider Name segment is required and is used to identify the individual or organizational billing entity. The following illustrates how information should be sent from March 19, 2007 May 22, NM101 Entity Identifier NM1 2010AA 85 (for Billing Provider) 85

7 Segment Loop NM102 Entity Type NM1 2010AA 1 (for Person) 2 (for Non-Person Entity) 1 NM103 Billing Provider Last or Organizational Name NM1 2010AA Last name of individual provider if value in NM102 = 1 or the DOE name of the organizational entity if value in NM102 = 2 NM104 Billing Provider First NM1 2010AA First name of individual provider if value in NM102 = 1 (this JOHN Name element is not required if NM102 = 2 ) NM108 Identification NM1 2010AA XX (for National Provider Identifier - NPI) XX NM109 Billing Provider Primary NM1 2010AA National Provider Identifier - NPI Identification Number REF01 Reference Identification REF 2010AA EI (for Employer s Identification Number) SY (for Social Security Number) EI REF02 REF01 REF02 Billing Provider Secondary Identification Number Reference Identification Billing Provider Secondary Identification Number REF 2010AA Employer s Identification Number or Social Security Number REF REF 2010AA 1D (for Medicaid Number Always used for Oklahoma Medicaid) (PLEASE NOTE: If NPI is sent in 2010AA-NM109, an additional 2010AA-REF segment must be sent with either the EI or SY qualifier in the REF01 element for Employer s Identification Number or Social Security Number, respectively.) 2010AA 10-character Provider assigned by OHCA (PLEASE NOTE: If additional 2010AA-REF segment with EI or SY qualifier is sent, the respective EIN or SSN must be present in the REF02 element.) 2010AA 24 (for Employer s Identification Number), 34 (for Social Security Number) or XX (for National Provider Identifier) 2010AA EIN or SSN or NPI (depending upon code qualifier in NM108). Revised 5/23/2007 Page 7 of 16 1D A NM108 Identification NM1 24 NM109 Billing Provider Primary NM Identification Number If NPI is available, that number must be used. Loop 2010AB-Pay-to Provider Name is situational; however, it is required if the Pay-to Provider is a different entity than the Billing Provider. The following illustrates how information should be sent from March 19, 2007 May 22, NM101 Entity Identifier NM1 2010AB 87 (for Pay-to Provider) 87

8 Segment Loop NM102 Entity Type NM1 2010AB 1 (for Person) 2 (for Non-Person Entity) 1 NM103 Pay-to Provider Last or Organizational Name NM1 2010AB Last name of individual provider if value in NM102 = 1 or the DOE name of the organizational entity if value in NM102 = 2 NM104 Pay-to Provider First NM1 2010AB First name of individual provider if value in NM102 = 1 (this JOHN Name element is not required if NM102 = 2 ) NM108 Identification NM1 2010AB XX (for National Provider Identifier - NPI) XX NM109 Pay-to Provider Primary NM1 2010AB National Provider Identifier - NPI Identification Number REF01 Reference Identification REF 2010AB EI (for Employer s Identification Number) SY (for Social Security Number) EI REF02 REF01 REF02 Pay-to Provider Additional Identifier Reference Identification Pay-to Provider Additional Identifier REF 2010AB Employer s Identification Number or Social Security Number REF REF 2010AB 1D (for Medicaid Number Always used for Oklahoma Medicaid) (PLEASE NOTE: If NPI is sent in 2010AA-NM109, an additional 2010AA-REF segment must be sent with either the EI or SY qualifier in the REF01 element for Employer s Identification Number or Social Security Number, respectively.) 2010AB 10-character Provider assigned by OHCA (PLEASE NOTE: If additional 2010AA-REF segment with EI or SY qualifier is sent, the respective EIN or SSN must be present in the REF02 element.) 2010AB 24 (for Employer s Identification Number), 34 (for Social Security Number) or XX (for National Provider Identifier) 2010AB EIN or SSN or NPI (depending upon code qualifier in NM108). Revised 5/23/2007 Page 8 of 16 1D A NM108 Identification NM1 24 NM109 Pay-to Provider Primary NM Identification Number If NPI is available, that number must be used. Please refer to pages of the 837 Professional Implementation Guide for specific information related to the use of the 2000B-HL segment. HL03 Hierarchical Level HL 2000B 22 (for Subscriber) HL*2*1*22 HL04 Hierarchical Child HL 2000B 0 (an Oklahoma Medicaid subscriber is the patient; therefore, HL*2*1*22*0

9 Segment Loop there will never be dependent claims) SBR01 Payer Responsibility SBR 2000B P (for Primary) P Sequence Number SBR04 Group or Plan Name SBR 2000B MEDICA MEDICA SBR09 Claim Filing Indicator SBR 2000B MC MC NM101 Entity Identifier NM1 2010BA IL (for Insured or Subscriber) IL NM102 Entity code NM1 2010BA 1 = Person 1 NM103 Subscriber Last Name NM1 2010BA Last Name of Subscriber (Insured) DOE NM104 Subscriber First Name NM1 2010BA First Name of Subscriber (Insured) JOHN NM108 Identification NM1 2010BA MI (for Member Identification Number) MI NM109 Subscriber Primary NM1 2010BA Member s 9-digit DHS-assigned Recipient Number Identifier N301 Subscriber Address Line N3 2010BA Street Address 555 N. MAIN N401 Subscriber City Name N4 2010BA City Name OKLAHOMA CITY N402 Subscriber State N4 2010BA State or Province OK N403 Subscriber Zip N4 2010BA Postal Zip (excluding punctuation and blanks See for Zip+4 usage) DMG01 Date/Time Period Format DMG 2010BA D8 (for Date Expressed in format CCYYMMDD) D8 DMG02 Subscriber (Patient) Birth DMG 2010BA Subscriber Date of Birth in CCYYMMDD format Date DMG03 Subscriber (Patient) DMG 2010BA F (for Female), M (for Male), U (for Unknown) M Gender NM101 Entity Identifier NM1 2010BB PR (for Payer) PR NM102 Entity Type NM1 2010BB 2 (for Non-Person Entity) 2 NM103 Payer Name NM1 2010BB OKLAHOMA HEALTH CARE AUTHORITY OKLAHOMA HEALTH CARE AUTHORITY NM108 Identification NM1 2010BB PI (for Payor Identification) or XV (for Health Care PI Financing Administration National Plan Required when the Revised 5/23/2007 Page 9 of 16

10 Segment Loop use of the National Plan is mandated) NM109 Payer Primary Identifier NM1 2010BB OHCA Tax Number CLM01 Patient Account Number CLM 2300 Number used by the submitter to identify the patient. This number is returned back in the CLP segment of the 835 transaction and allows for claim tracking by the submitter. The maximum number of characters allowed is 20. CLM02 Total Claim Charge Amount CLM 2300 Amount equal to the total of all submitted service lines for the claim (See 2400-SV102 Line Item Charge Amount for further explanation) CLM05-1 Facility Type CLM 2300 Refer to Source 237 for complete list of applicable values. 11 CLM05-3 Claim Frequency Type CLM (for Original), 7 (for Replacement) or 8 (for Void) (PLEASE NOTE: 7 and 8 should only be sent when replacing or voiding a PA claim. If original claim was DENIED, a value of 1 should be sent with the resubmission.) For more information, please refer to CLM 2300 Y (for Yes indicates that the provider signature is on file) Y CLM06 Provider Signature on File Indicator CLM07 Medicare Assignment CLM 2300 A (for Assigned - indicates that the provider accepts Medicare A assignment) CLM08 Benefits Assignment CLM 2300 Y (for Yes - indicates that the insured authorizes benefits to be Y Certification Indicator assigned to the provider) CLM09 Release of Information CLM 2300 Y (for Yes indicates that the provider has a Signed Statement Y Permitting Release of Medical Billing Data Related to a Claim) CLM10 Patient Signature Source CLM 2300 B (for Signed signature authorization form or forms for both B HCFA-1500 Claim Form block 12 and block 13 are on file) The following element (CLM11) is required if 2300-DTP01=439. CLM11-1 Accident/Employment/ AA Related Causes CLM 2300 AA (for Auto Accident), AP (for Another Party Responsible), EM (for Employment) or OA (for Other Accident). If more than one code applies, elements CLM11-2 or CLM11-3 should also be used. CLM11-4 Auto Accident State or CLM 2300 State postal code (i.e., OK for Oklahoma). This element is OK Revised 5/23/2007 Page 10 of 16 1

11 Province Segment Loop required if CLM11-1, 2 or 3 = AA. CLM12 Special Program CLM 2300 If special program is EPSDT, choose 01. For complete list of applicable codes, see Implementation Guide Addenda. 01 CLM20 Delay Reason CLM 2300 See 837 Professional Implementation Guide for accepted values. 9 This element is required when a claim is submitted late (after contracted date of filing limitation). The Accident Date DTP segment (with 439 qualifier) is required if CLM11-1, CLM11-2 or CLM11-3 = AA, AP, EM or OA. DTP01 Date/Time DTP (for Accident) Required if CLM11-1, CLM11-2 or 439 CLM11-3 = AA, AP, EM or OA. DTP02 Date/Time Period Format DTP 2300 D8 (for Date Expressed in Format CCYYMMDD) DT (for Date and Time Expressed in Format CCYYMMDDHHMM Required if accident hour is known). D8 DTP03 Accident Date DTP 2300 Accident Date in CCYYMMDD or CCYYMMDDHHMM format The 2300-PWK-Claim Supplemental Information segment is required when there is paper documentation supporting the claim. PWK01 Attachment Report Type PWK 2300 indicating the title or contents of a document, report or supporting item. See page 215 in the Implementation Guide for OZ PWK02 PWK05 PWK06 Attachment Transmission Identification Attachment Control Number appropriate codes. PWK 2300 BM = By Mail, FX = By Fax. These are the only two FX methods accepted by OHCA. PWK 2300 AC (for Attachment Control Number) AC PWK 2300 Unique identifying paper documentation. This value must match ACN on OHCA form HCA (if DTP02 = D8 ) or (if DTP02 = DT ) The 2300-CN1-Contract Information segment is required if the provider is contractually obligated to provide contract information on the claim. CN101 Contract Type CN (for Other) 09 CN104 Contract CN NI (for Indian Providers billing for non-indian patients) DM (for Behavioral Health Facility contracted with DMHSAS) A (for BH Case Mgmt., Public or Private, Over 21) C (for BH Case Mgmt., Public or Private, Under 21) Revised 5/23/2007 Page 11 of 16 NI

12 Segment Loop DA (for BH Case Mgmt., DMHSAS Contracted, Over 21) DC (for BH Case Mgmt., DMHSAS Contracted, Under 21) The 2300-REF-Original Reference Number (ICN) segment is required when submitting a replacement claim or request to void the original claim as indicated by 7 or 8 in 2300-CLM05-3. REF01 Reference Identification REF 2300 F8 (for Original Reference Number) F8 REF02 Claim Original Reference Number REF digit ICN from original claim The 2300-REF-Clinical Laboratory Improvement Amendment (CLIA) Number is required for claims submitted by laboratories performing tests covered by the CLIA Act. REF01 Reference Identification REF 2300 X4 (for Clinical Laboratory Improvement Amendment X4 Number) REF02 Clinical Laboratory Improvement Amendment Number REF 2300 CLIA Number 12D The 2310A-Referring Provider Name segment is required for all Sooner Care referrals. The following illustrates how information should be sent from March 19, 2007 May 22, NM101 Entity Identifier NM1 2310A DN (for Referring Provider) DN NM102 Entity Type NM1 2310A 1 (for Person) 1 2 (for Non-Person Entity) NM108 Identification NM1 2310A XX (for National Provider Identifier - NPI) XX NM109 Referring Provider Primary NM1 2310A National Provider Identifier - NPI Identifier NM108 Identification NM1 2310A 24 (for Employer s Identification Number), 34 (for Social Security Number) or XX (for National Provider Identifier) 24 NM109 Referring Provider Primary NM1 2310A EIN or SSN or NPI (depending upon code qualifier in NM108) Identifier (PLEASE NOTE: This element is required if EIN (Tax ) or NPI is known. If NPI is available, that number must be used.) The 2310A-PRV-Referring Provider Specialty Information segment is required when the provider taxonomy code affects adjudication of the claim. PRV01 Provider PRV 2310A RF (for Referring) RF PRV02 Reference Identification PRV 2310A ZZ (for Mutually Defined Health Care Provider Taxonomy ZZ Revised 5/23/2007 Page 12 of 16

13 PRV03 REF01 Provider Taxonomy (Specialty) Reference Identification Segment Loop list) PRV 2310A The Health Care Provider Taxonomy (Provider Specialty ), available at the Washington Publishing Company Internet website: REF 2310A 1D (for Medicaid Number Always used for Oklahoma Medicaid) 363LP0200N REF02 Referring Provider Secondary Identifier REF 2310A 10-character Provider assigned by OHCA A The 2310B-Rendering Provider Name segment is required when a provider other than the Billing or Pay-to Provider renders the services. The following illustrates how information should be sent from March 19, 2007 May 22, NM101 Entity Identifier NM1 2310B 82 (for Rendering Provider) 82 NM102 Entity Type NM1 2310B 1 (for Person) 1 2 (for Non-Person Entity) NM108 Identification NM1 2310B XX (for National Provider Identifier - NPI) XX NM109 Rendering Provider NM1 2310B National Provider Identifier - NPI Primary Identifier NM108 Identification NM1 2310B 24 (for Employer s Identification Number), 34 (for Social Security Number) or XX (for National Provider Identifier) 24 NM109 Rendering Provider Primary Identifier NM1 2310B EIN or SSN or NPI (depending upon code qualifier in NM108) If NPI is available, that number must be used. The 2310B-PRV-Rendering Provider Specialty Information segment is required when the provider taxonomy code affects adjudication of the claim and the Rendering Provider is a different entity than the Billing/Pay-to Provider. PRV01 Provider PRV 2310B PE (for Performing) PE PRV02 Reference Identification PRV 2310B ZZ (for Mutually Defined) ZZ PRV03 Provider Taxonomy (Specialty) PRV 2310B The Health Care Provider Taxonomy (Provider Specialty ), available at the Washington Publishing Company 363LP0200N REF01 Reference Identification Internet website: REF 2310B 1D (for Medicaid Number Always used for Oklahoma Medicaid) REF02 Rendering Provider REF 2310B 10-character Provider assigned by OHCA B Secondary Identifier Revised 5/23/2007 Page 13 of 16 1D 1D

14 Segment Loop The 2310D-Service Facility Location segment is required when the services were rendered in a location different than that specified in the Billing or Pay-to loops. The following illustrates how information should be sent from March 19, 2007 May 22, NM101 Entity Identifier NM1 2310D 77 (for Service Location) FA FA (for Facility) LI (for Independent Lab) TL (for Testing Laboratory) NM102 Entity Type NM1 2310D 2 (for Non-Person Entity) 2 NM108 Identification NM1 2310D XX (for National Provider Identifier - NPI) XX NM109 Laboratory/Facility NM1 2310D National Provider Identifier - NPI Primary Identifier NM108 Identification NM1 2310D 24 (for Employer s Identification Number) or XX (for National Provider Identifier) 24 NM109 Laboratory/Facility NM1 2310D EIN or NPI (depending upon code qualifier in NM108) Primary Identifier (PLEASE NOTE: This element is required if EIN (Tax ) or NPI is known. If NPI is available, that number must be used.) N301 Laboratory/Facility N3 2310D Street Address 101 ELM STREET Address N401 Laboratory/Facility City N4 2310D City Name OKLAHOMA CITY N402 Laboratory/Facility State N4 2310D State or Province OK N403 Laboratory/Facility Zip N4 2310D Postal (excluding punctuation and blanks See Format Example for Zip+4 usage) REF01 Reference Identification REF 2310D 1D (for Medicaid Number Always used for Oklahoma Medicaid) REF02 Laboratory/Facility REF 2310D 10-character Provider assigned by OHCA D Secondary Identifier LX01 Line Counter LX 2400 Service line number incremented by 1 for each service line. LX*1 SV102 Line Item Charge Amount SV Submitted charge amount (PLEASE NOTE: The combined total of the 2400-SV102 submitted charges must equal the Total Claim Charge Amount in 2300-CLM02.) Revised 5/23/2007 Page 14 of 16 1D

15 Segment Loop SV105 Facility SV Refer to Source 237 for complete list of applicable values. 11 (PLEASE NOTE: This field is required if value is different than value in loop 2300-CLM05-1.) The 2400-SV107-Diagnosis Pointer element is required if 2300-HI Diagnosis segment is sent. SV107-1 Diagnosis Pointer SV through 8 are acceptable values. This pointer is used for 1 the primary diagnosis. Remaining diagnosis code pointers are used in sub-elements SV107-2, SV107-3 and SV107-4 in declining level of importance to service line. SV109 Emergency Indicator SV Y is required if service provided was emergency-related; Y otherwise, element should not be populated. SV111 EPSDT Indicator SV Y is required if there is Early and Periodic Screening, Y Diagnosis and Treatment of Children (EPSDT) involvement; otherwise, element should not be populated. SV112 Family Planning Indicator SV Y is required if there is Family Planning Services involvement; Y otherwise, element should not be populated. The 2400-CN1-Contract Information segment overwrites CN1 information contained at the 2300 loop and is required if the service line information is different than the information provided at the claim level (Loop- 2300). CN101 Contract Type CN (for Other) 09 CN104 Contract CN NI (for Indian Providers billing for non-indian patients) DM (for Behavioral Health Facility contracted with DMHSAS) A (for BH Case Mgmt., Public or Private, Over 21) C (for BH Case Mgmt., Public or Private, Under 21) DA (for BH Case Mgmt., DMHSAS Contracted, Over 21) DC (for BH Case Mgmt., DMHSAS Contracted, Under 21) Trailer 837 Professional NI Element Segment Loop Transaction Set Trailer Indicates the end of the Transaction Set Revised 5/23/2007 Page 15 of 16

16 SE01 Transaction Segment Count SE N/A Total number of segments included in a transaction set (including the ST and SE segments) 42 SE02 Transaction Set Control Number SE N/A Unique number to the interchange that must be identical to value 0001 in ST02 Functional Group Trailer GE01 Number of Transaction Sets Included GE N/A Total number of transaction sets included in the functional group 1 GE02 Group Control Number GE N/A Unique number assigned by the sender that must be identical to GS Interchange Control Trailer IEA01 Number of Included Functional Groups IEA N/A Count of the number of functional groups included in an interchange 1 IEA02 Interchange Control Number IEA N/A Control number assigned by the interchange sender that should be 9 characters and be identical to the value in ISA13 For questions related to this transaction set, please contact the EDI Help Desk at (405) Revised 5/23/2007 Page 16 of 16