Standard HIPAA Companion Guide

Transcription

1 tandard HIPAA Companion Guide 837 Health Care Claim: Institutional an Francisco Health Plan efers to the Implementation Guide Based On AC X12 Version X223A2 Last Updated: eptember 23, 2014 Effective Date: October 1, 2014 Contact: IT Production ervices Version: 2.2 an Francisco Health Plan 201 Third treet, 7 th Floor an Francisco, CA

2 Table of Contents Document evision / Version Control... 3 Introduction... 4 Acceptable Data Policy... 4 equired and Loops... 4 VALIDATION OF CLAIM... 5 VALIDATION OF ENCOUNTE... 5 IMPLEMENTATION... 6 LAYOUT... 6 File Headers... 8 ubmitter and eceiver Billing Provider Detail ubscriber Detail Patient Detail Claim Level Detail Claim Line Level Detail File Trailers OTHE INFOMATION ICD-10 Diagnosis s Appendix A ample Claim Data Appendix B HCPC s and NDC Equivalents Page 2

3 Document evision / Version Control Ver. Date Comments / Details of revision Modified By /15/2013 Initial Draft amuel Dodda /30/2013 Final Version Tony Ambrose 2.1 8/29/2014 Updated to incorporate DHC requirements oger Excell/ Wil Trevizo 2.2 9/23/2014 Corrections made to required/situational status of the 2320 OI segment, and the 2330A and 2330B loops Modifications made to the notes of the CLM05-1 Added file naming convention section Wil Trevizo Page 3

4 Introduction This Companion Guide was prepared to assist an Francisco Health Plan (FHP) partners in implementing electronic Institutional Claims/Encounter exchange. This Companion Guide represents only the pertinent data elements for FHP and its trading partners and is not be representative of the full X T3. It is a tool to be used in conjunction with the X Institutional Health Care Claim Implementation Guide. If necessary, FHP shall provide a specific addendum to this guide to each partner to indicate which fields have hardcoded values to cover both parties business requirements. Acceptable Data Policy Line, egment, Element and ub-element Terminators Files should follow industry standard practices for line, segment and element terminators. Carriage returns and line feed characters are acceptable for line terminators. tandard formatting of the initial IA line to dynamically determine segment, element and sub-element terminators must be exercised. ending data with a non-standard IA header in which the terminators cannot be dynamically determined will result in the rejection of the entire file. HIPAA egments This companion guide describes the elements FHP can presently extract from an 837 Institutional file. If additional data is sent in standard 837I format as described in the HIPAA X223A2 Implementation Guide, it will be ignored until such time as both trading partners agree to implement the additional data fields. If additional data is sent that is not strictly defined as in the HIPAA X223A2 Implementation Guide, this will result in the rejection of the entire file. equired and Loops In this guide, loops, segments, and data elements are marked as situational or required. Even though a segment may be marked as situational, some data elements within that segment may be marked as required. In these cases, if that situational segment is included, those required elements are necessary. In general, anything marked as situational is not explicitly required, but there are situations in which they may be necessary. For example, the 2300 EF*F8, Payer Claim Control Number, is a situational segment, but the segment becomes required when Page 4

5 submitting a replacement or void claim/encounter record. There are several other situations when this is also the case. Excerpted from the HIPAA T3: The usage designator of a loop s beginning segment indicates the usage of the loop. If a loop is used, the first segment of that loop is equired () even if it is marked (). If the usage of the first segment in a loop is marked required, the loop must occur at least once unless it is nested in a loop that is not being used. A note on the required initial segment of a nested loop will indicate dependency on the higher level loop. If the first segment is, there will be a segment note addressing use of the loop. Any required segments in loops beginning with a segment only occur when the loop is used. For an example of this, see Loop ID-2010AA Billing Provider. In the 2010AA loop, if the loop is used, the initial segment, NM1 Billing Provider Name, must be used. N3 and N4, EF-Billing Provider TAX ID segments are required. VALIDATION OF CLAIM 1. Pre-Processor validation of claims (and encounters sent through adjudication system) is based on: a. HIPAA Compliance b. Member match and Provider match 2. Claims and encounters passing Pre-Processor Validation are accepted into the Adjudication system for processing 3. Claims and encounters that fail Per-Processor Validation will be rejected and returned to the ubmitter. 4. Institutional claims and encounters received before 10:00 AM on a business day will be processed on the same day by 6:00 PM. Institutional claims and encounters received on a business day/non-business day after 10:00 AM will be processed on the next business day by 6:00 PM. VALIDATION OF ENCOUNTE 1. FHP Enterprise Data Warehouse - Encounters are routed into our Data Warehouse for validation on HIPAA Compliance 2. Encounters that fail this validation will be rejected and returned to the ubmitter via Error eports on the following Business day. 3. Institutional encounters before 10:00 AM on a business day will be processed on the same day by 6:00 PM. Institutional encounters received on a business day/non-business day after 10:00 AM will be processed on the next business day by 6:00 PM. Page 5

6 IMPLEMENTATION FHP exchanges claim and encounter data with its trading partners via FTP. A signed Trading Partner Agreement must be completed prior to FTP connectivity set up. Contact EDI Customer upport for more information at production_services@sfhp.org Upon signing the Trading Partner Agreement, necessary documentation along with the User ID and Password will be transmitted to the Trading Partner securely. An 837I Enrollment form is submitted by the Trading Partner, which includes the Tax ID. FHP completes the 837I Enrollment and an 837I test file is requested from the Trading Partner (Utilized for test cycle). A minimum of two successful test cycles are required before a Trading Partner can be approved for production 837I file exchange. NAMING CONVENTION Please use the following naming convention when submitting Professional Encounter and Claim 837 files to FHP: [ubmitter ID]-837P-[File Create Date CCYYMMDDhhmmss]-[Product ].txt All encounter ubmitter IDs are three digit alpha codes. Claim submitter codes may vary in length and can contain alpha and numeric values. FHP must agree with submitters on ubmitter IDs prior to file submission. Example: Encounter Files ABC-837I MC.txt DEF-837I HF.txt Claim Files ABCD-837I FHP_MC.txt EFG05-837I HF_HK.txt Product s: FHP = an Francisco Health Plan FHP_MC = FHP Medi-Cal FHP_HK = FHP Healthy Kids FHP_HW = FHP Healthy Workers HF = Healthy an Francisco Page 6

7 LAYOUT The Implementation Guide groups the data into Levels, Loops and egments. A Loop is made of one or more egments, and a Level is made of one or more Loops. Data segments are explained in the table below with the following columns: 1. Loop: The Loop ID from the Implementation Guide. The first level of reference to locate any element in the Implementation Guide. 2. Element: The Element ID from the Implementation Guide. The second level of reference to locate any element in the Implementation Guide. 3. Name: The Industry Name from the Implementation Guide. The standard name is used when no industry name was available. 4. Instructions & Examples: Provides additional information for data required in a segment. 5. The below table represents only those fields that FHP requires a specific value in or has additional guidance on what the value sent in the response means. The table does not represent all of the information required (such as Element ID, Type, Length, and Usage) for a successful transaction. The T3 should be reviewed for that information. Page 7

8 File Headers Loop Element Name Instructions & Examples IA Interchange EX: Control Header IA*00*\\\\\\\\\\*00*\\\\\\\\\ \*ZZ*XXXXXXXXXX\\\\\*ZZ*FHP\\ \\\\\\\\\*121001*1600*^*00501* *0*P*>~ equired/ The IA is a fixed record length segment and all positions within each of the data elements MUT BE FILLED. paces in the example are represented by \ for clarity IA01 Authorization This element will carry the value: 00 - No Authorization Present (No Meaningful in I02) 03 - Additional Data IA02 IA03 IA04 IA05 IA06 IA07 Authorization ecurity ecurity Interchange ID Interchange ender ID Interchange ID Interchange eceiver ID No Authorization will be sent by FHP (Leave Blank) This element will always carry the value 00 No ecurity will be sent by FHP (Leave Blank) 30 U.. Federal Tax Number ZZ Mutually Defined XXXXXXXXXX 30 U.. Federal Tax Number ZZ Mutually Defined IA08 This element is assigned by FHP. Ex: FHP15 or FHP. IA09 Interchange Date YYMMDD Date Format IA10 Interchange Time HHMM Time Format IA11 epetition This element is assigned by ender. ^ eparator IA12 Interchange Control Version Number Page 8

9 Loop Element Name Instructions & Examples IA13 IA14 IA15 IA16 G G01 G02 G03 Interchange Control Number Acknowledgement equest Interchange Usage Indicator Component Element eparator Functional Group Header Functional Identifier Application ender's Application eceiver's A unique positive unsigned number assigned by FHP, must be identical to IEA02 EX: No Acknowledgement equest P Production Data T Test Data > G*HC*XXXXXXXXX*FHP15* *1600* 22220*X*005010X223A2~ HC Health Care Claim (837) ender defines. This element is same as IA08 G04 Date Functional Group Creation Date in CCYYMMDD format equired/ G05 Time Functional Group Creation Date in HHMM format G06 G07 G08 T T01 T02 Group Control Number esponsible Agency Version/elease/I ndustry Identifier Transaction et Header Transaction et Identifier Transaction et Control Number This may be same as IA13 and GE02 or unique positive number. X - Accredited tandards Committee X X223A1 - tandards Approved for Publication by AC X12 Procedures eview Board T*837*0001*005010X223A2~ 837 Health Care Claim This element will contain a unique transaction set control number assigned by FHP. EX: 0001 The Transaction et Control Number in T02 and E02 must be identical. T03 Implementation Convention eference This field contains the same value as G08. Page 9

10 Loop Element Name Instructions & Examples BHT Beginning of BHT*0019*00*5056* *1609*CH~ Hierarchical Transaction BHT01 Hierarchical 0019 ource: ubscriber, tructure Dependent BHT02 BHT03 Transaction et Purpose eference Identifier 00 Original Transmission (Electronic) 18 eissue (Electronic) Originator Application Transaction Identifier assigned by the submitter s system. This number operates as a batch control number. BHT04 Date Transaction et Creation Date in CCYYMMDD format BHT05 Time Transaction et Creation Time in HHMM format BHT06 Transaction Type 31 ubrogation Demand CH Claims Chargeable and Capitated Claims P eporting equired/ Page 10

11 ubmitter and eceiver Loop Element Name Instructions & Examples equired/ 1000A NM1 ubmitter Name NM1*41*2*AN FANCICO HOPITAL*****46* ~ 1000A NM101 Entity Identifier 41 ubmitter 1000A NM102 Entity Type 2 Non-Person 1000A NM103 Organization Name Organization Name 1000A NM Electronic Transmitter Number (ETIN) 1000A NM109 ubmitter Identifier 1000A PE ubmitter EDI Contact 1000A Contact Function PE01 ubmitter Identifier PE*IC*BUINE OFFICE*TE* *FX* ~ IC Contact 1000A PE02 Name ubmitter Contact Name 1000A PE03 Communication TE Telephone Number Number 1000A PE04 Communication Communication Number Number 1000A PE05 Communication FX Fax Number Number 1000A PE06 Communication Communication Number Number 1000B NM1 eceiver Name NM1*40*2*F HEALTH PLAN*****46*FHP~ 1000B NM101 Entity Identifier 40 eceiver 1000B NM102 Entity Type 2 Non-Person 1000B NM103 Organization Name F Health Plan - Organization Name 1000B NM B NM109 ubmitter Identifier 46 Electronic Transmitter Number (ETIN) This element will always the carry the value: FHP Page 11

12 Billing Provider Detail Loop Element Name Instructions & Examples equired/ 2000A HL Billing Provider Hierarchical Level HL*1**20*1~ 2000A HL01 Hierarchical ID The first HL01 within each T-E envelope must Number begin with 1, and be incremented by one each time an HL is used in the transaction. 2000A HL03 Hierarchical Level 20 ource 2000A HL04 Hierarchical Child 2000A PV Billing Provider pecialty 1 Additional ubordinate HL Data egment in This Hierarchical tructure. PV*BI*PXC*261QF0400X~ 2000A PV01 Provider BI Billing 2000A PV02 eference 2000A PV03 eference 2010AA NM1 Billing Provider Name 2010AA NM101 Entity Identifier 2010AA NM102 Entity Type 2010AA NM103 Organization Name 2010AA NM AA NM109 ubmitter Identifier 2010AA N3 Billing Provider Address 2010AA N301 Address 2010AA N302 Address PXC Health Care Provider Taxonomy Billing Provider Taxonomy NM1*85*2*TOM WADDELL HLTH CNT*****XX* ~ 85 Billing Provider 2 Non-Person Organization Name XX Centers for Medicare and Medicaid ervices National Provider Identifier (NPI) Billing Provider Identifier FHP Notes: NPI is required for all providers. Please note that if Billing Provider s NPI is not provided; Claim will be rejected by FHP. N3*10 3D AVE~ FHP Notes: Must be a physical address Billing Provider Address Line Additional Billing Provider Address Line Page 12

13 Loop Element Name Instructions & Examples equired/ 2010AA N4 Billing Provider N4*AN FANCICO*CA* ~ City, tate, Zip 2010AA N401 City Name Billing Provider City Name 2010AA N402 tate or Province Billing Provider tate 2010AA N403 Postal Billing Provider Postal FHP Notes: Must be 9 digits 2010AA EF Billing Provider EF*EI* ~ Tax 2010AA EF01 eference EI Employer Number 2010AA EF02 eference Billing Provider Tax Number 2010AA PE Billing Provider Contact 2010AA Contact Function PE01 PE*IC*BUINE OFFICE*TE* *FX* ~ IC Contact 2010AA PE02 Name ubmitter Contact Name 2010AA PE03 Communication TE Telephone Number Number 2010AA PE04 Communication Communication Number Number 2010AA PE05 Communication FX Fax Number Number 2010AA PE06 Communication Number Communication Number 2010AB NM1 Pay-To Address Name NM1*87*2~ FHP Notes: the 2010AB loop should be used when the remit address differs from the physical address in the 2010AA Billing Provider loop 2010AB NM101 Entity Identifier 87 Pay-to Provider 2010AB NM102 Entity Type 2 Non-Person 2010AB N3 Pay-To Address N3*100 3D AVE~ 2010AB N301 Address 2010AB N302 Address Pay-to Provider Address Line Additional Address Line Page 13

14 Loop Element Name Instructions & Examples equired/ 2010AB N4 Pay-To City, N4*AN FANCICO*CA* ~ tate, Zip 2010AB N401 City Name Pay-to Provider City Name 2010AB N402 tate or Province Pay-to Provider tate 2010AB N403 Postal Pay-to Provider Postal Page 14

15 ubscriber Detail Loop Element Name Instructions & Examples equired/ 2000B HL ubscriber Hierarchical Level HL*2*1*22*0~ 2000B HL01 Hierarchical ID The first HL01 within each T-E envelope must Number begin with 1, and be incremented by one each time an HL is used in the transaction. 2000B HL02 Hierarchical Parent ID Number 2000B HL03 Hierarchical Level 2000B HL04 Hierarchical Child 2000B B ubscriber 2000B B01 Payer esponsibility equence Number 2000B B02 Individual elationship 2000B B03 eference 2010BA NM1 UBCIBE NAME 2010BA NM101 Entity Identifier 2010BA NM102 Entity Type This element identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. Current HL segment is subordinate of HL 1 and will carry the value 1 22 ubscriber 0 No ubordinate Patient HL egment in This Hierarchical tructure. 1 Additional ubordinate Patient HL Data egment in This Hierarchical tructure. B*P*18*CHN******CI~ P Primary econdary T Tertiary 18 elf ubscriber Group or Policy Number: This element will contain a 3 letter representing ubscriber Group or a 14 digit and letter representing Policy Number EX: ABC ubscriber Group C26069 Policy Number NM1*IL*1*ANDE*LEX****MI* C~ IL Insured or ubscriber 1 Person 2010BA NM103 Name Last ubscriber Last Name 2010BA NM104 Name First ubscriber First Name 2010BA NM105 Name Middle ubscriber Middle Name 2010BA NM107 Name uffix ubscriber Name uffix Page 15

16 Loop Element Name Instructions & Examples equired/ 2010BA NM108 MI Member Number 2010BA NM Digit FHP ID or CIN 2010BA N3 ubscriber N3*1000 4D AVE~ Address 2010BA N301 Address ubscriber Address Line 2010BA N302 Address Additional Address Line 2010BA N4 ubscriber City, N4*AN FANCICO*CA* ~ tate, Zip 2010BA N401 City Name ubscriber City Name 2010BA N402 tate ubscriber tate 2010BA N403 Postal ubscriber Zip 2010BA DMG ubscriber DMG*D8* *M~ Demographic 2010BA DMG01 Date Time Period D8 Date Expressed in Format CCYYMMDD Format 2010BA DMG02 Date Time Period ubscriber Date of Birth 2010BA DMG03 Gender F Female M Male U Unknown 2010BB NM1 Payer Name NM1*P*2*an Francisco Health Plan*****PI*FHP~ 2010BB NM101 Entity Identifier P Payer 2010BB NM102 Entity Type 2 Non- Person 2010BB NM103 Organization Name Payer Name 2010BB NM108 PI Payer XV Centers for Medicare and Medicaid ervices PlanID 2010BB NM109 Payer Primary Identifier 2010BB N3 Payer Address N3*1002 4D AVE~ 2010BB N301 Address 2010BB N302 Address Payer Address Line Additional Address Line Page 16

17 Loop Element Name Instructions & Examples equired/ 2010BB N4 Payer City, N4*AN FANCICO*CA* ~ tate, Zip 2010BB N401 City Name Payer City Name 2010BB N402 tate Payer tate 2010BB N403 Postal Payer Postal Page 17

18 Patient Detail Loop Element Name Instructions & Examples equired/ 2000C HL Patient HL*3*2*23*0~ Hierarchical Level T3 Notes: If a patient is a dependent of a subscriber and can be uniquely identified to the payer by a unique Number, then the patient is considered the subscriber and is to be identified in the ubscriber Level. 2000C HL01 Hierarchical ID Number 2000C HL02 Hierarchical Parent ID Number 2000C HL03 Hierarchical Level 2000C HL04 Hierarchical Child 2000C PAT Patient FHP Notes: This egment will only be used when services are provided to a Newborn whose mother is an FHP subscriber The first HL01 within each T-E envelope must be 1, and be incremented by one each time an HL is used in the transaction. This element identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. 23 Dependent 0 No ubordinate HL egment is allowed in this Patient Hierarchical tructure. PAT*19~ FHP Notes: This egment will only be used when services are provided to a Newborn whose mother is an FHP subscriber 19 - Child 2000C PAT01 Individual elationship 2010CA NM1 Patient Name NM1*QC*1*ANDY*LEE****MI* C~ 2010CA NM101 Entity Identifier 2010CA NM102 Entity Type FHP Notes: This egment will only be used when services are provided to a Newborn whose mother is an FHP subscriber QC Patient 1 Person 2010CA NM103 Name Last Patient Last Name 2010CA NM104 Name First Patient First Name 2010CA NM105 Name Middle Patient Middle Name 2010CA NM107 Name uffix Patient Name uffix Page 18

19 Loop Element Name Instructions & Examples equired/ 2010CA N3 Address N3*123 Main treet~ FHP Notes: This egment will only be used when services are provided to a Newborn whose mother is an FHP subscriber 2010CA N301 Patient Address First Address line Line 2010CA N302 Patient Address econd Address Line Line 2010CA N4 Patient City, tate, Zip N4*AN FANCICO*CA* ~ FHP Notes: This egment will only be used when services are provided to a Newborn whose mother is an FHP subscriber 2010CA N401 City Name Patient City 2010CA N402 tate or Provence Patient tate code 2010CA N403 Postal Patient Zip 2010CA DMG Patient Demographic 2010CA DMG01 Date Time Period Format DMG*D8* *F~ FHP Notes: This egment will only be used when services are provided to a Newborn whose mother is an FHP subscriber D8 Date Expressed in Format CCYYMMDD 2010CA DMG02 Date Time Period Patient Date of Birth 2010CA DMG03 Gender F Female M Male U Unknown Page 19

20 Claim Level Detail Loop Element Name Instructions & Examples equired/ 2300 CLM Claim CLM* *150.00***13>A>1**C*Y *Y~ 2300 CLM01 Claim ubmitter s Patient Control Number Identifier 2300 CLM02 Monetary Amount Total Claim Charge Amount 2300 CLM05-1 Facility Value 2300 CLM05-2 Facility 2300 CLM05-3 Claim Frequency Type 2300 CLM07 Provider Accept Assignment 2300 CLM08 Yes/No Condition or esponse The most common facility codes: 11 Office 13 Assisted Living Facility 20 Urgent Care Facility 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency oom - Hospital 24 Ambulatory urgical Center 25 Birthing Center 34 Hospice 41 Ambulance - Land A Uniform Billing Claim Form Bill Type CODE OUCE 236: Uniform Billing Claim Form Bill Type 1 Original (Admit through discharge claim) 6 Corrected (Adjustment of prior claim) 34 Hospice 7 eplacement (eplacement of prior claim) 8 Void (Void/Cancellation of prior claim) 2 Interim - First Claim 3 Interim - Continuing Claim 4 Interim - Last Claim CODE OUCE 235: Claim Frequency Type Assignment or Plan Participation A Assigned B Assignment Accepted on Clinical Lab ervices Only C Not Assigned Benefit Assignment Certification Indicator. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. Y Yes N No W Not Applicable Page 20

21 Loop Element Name Instructions & Examples equired/ 2300 CLM09 elease of The elease of response is limited to the information carried in this claim. I Informed Consent to elease Medical for Conditions or Diagnoses egulated by Federal tatutes Y Yes, Provider has a igned tatement Permitting elease of Medical Billing Data elated to a Claim 2300 CLM20 Delay eason Delay eason 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 5 Delay in upplying Billing Forms 6 Delay in Delivery of Custom-made Appliances 7 Third Party Processing Delay 8 Delay In Eligibility Determination 9 Original Claim ejected or Denied Due to a eason Unrelated to the Billing Limitation ules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 2300 DTP Discharge Hour DTP*096*TM*1700~ FHP Note: equired on all final inpatient claims 2300 DTP01 Date/Time 096 Discharge 2300 DTP02 Date Time Period TM ange of Dates in Format HHMM Format 2300 DTP03 Date Time Period Discharge Time 2300 DTP tatement DTP*434*D8* ~ Dates 2300 DTP01 Date/Time 434 tatement 2300 DTP02 Date Time Period D8 ange of Dates in Format Format CCYYMMDD-CCYYMMDD 2300 DTP03 Date Time Period Dates 2300 DTP Admission Date/Hour 2300 DTP01 Date/Time DTP*435*D8* ~ FHP Note: equired on all inpatient claims 434 tatement Page 21

22 Loop Element Name Instructions & Examples equired/ 2300 DTP02 Date Time Period D8 Date in Format CCYYMMDD Format DT Date in Format CCYMMDDHHMM 2300 DTP03 Date Time Period Date and Hour 2300 CL1 Institutional Claim 2300 CL101 Admission Type 2300 CL102 Admission ource 2300 CL103 Patient tatus CL1*1*7*30~ indicating priority of admission or visit CODE OUCE 231: Priority (type) of admission or visit equired for all inpatient and outpatient services. CODE OUCE 230: Admission ource indicating patient status as of the statement covers through date 2300 EF ervice Authorization Exception 2300 EF01 eference 2300 EF02 eference 2300 EF eferral Number 2300 EF01 eference 2300 EF02 eference 2300 EF Prior Authorization 2300 EF01 eference 2300 EF02 eference CODE OUCE 239: Patient tatus EF*4N*1~ 4N pecial Payment eference Number Allowable values for this element are: 1 Immediate/Urgent Care 2 ervices endered in a etroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 equest from County for econd Opinion to Determine if ecipient Can Work 6 equest for Override Pending 7 pecial Handling EF*9F*12345~ 9F eferral Number eferral Number EF*G1*12345~ G1 Prior Authorization Number Prior Authorization Number Page 22

23 Loop Element Name Instructions & Examples equired/ 2300 EF Payer Claim EF*F8* ~ Control Number FHP Note: equired for adjusting or voiding previously submitted records. Use the CLM01 value from the original claims/encounters routed to Enterprise Data Warehouse. Use the Adjudication ystem ID for claims/encounters routed to adjudication system EF01 eference F8 Original eference Number 2300 EF02 eference Payer Claim Control Number 2300 EF Claim Identifier EF*D9* ~ For Transmission Intermediaries 2300 EF01 eference D9 Claim Number 2300 EF02 eference Value Added Network Trace Number 2300 EF Medical ecord EF*EA* ~ Number 2300 EF01 eference EA Medical ecord Number 2300 EF02 eference Medical ecord Number 2300 NTE Claim Note NTE*ALG*PENICILLIN~ Page 23

24 Loop Element Name Instructions & Examples equired/ 2300 NTE01 Note eference ALG Allergies DCP Goals, ehabilitation Potential, or Discharge Plans DGN Diagnosis Description DME Durable Medical Equipment (DME) and upplies MED Medications NT Nutritional equirements ODT Orders for Disciplines and Treatments HB Functional Limitations, eason Homebound, or Both LH easons Patient Leaves Home HN Times and easons Patient Not at Home ET Unusual Home, ocial Environment, or Both FM afety Measures PT upplementary Plan of Treatment UPI Updated 2300 NTE02 Description Claim Note Text 2300 NTE Claim Note NTE*ADD*PATIENT FELL AT HOME, LIABILITY~ 2300 NTE01 Note eference ADD Additional information 2300 NTE02 Description Claim Note Text 2300 HI Principal Diagnosis 2300 HI01-1 Health Care HI*BK>49300~ List : ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis 2300 HI01-2 Industry Diagnosis Page 24

25 Loop Element Name Instructions & Examples equired/ 2300 HI01-9 Yes/No Condition or esponse Present On Admission Indicator Used to identify the diagnosis onset as it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not HI Admitting Diagnosis 2300 HI01-1 Health Care N No U Unknown W Not Applicable Y Yes HI*BJ>99762~ FHP Note: equired for Inpatient Admissions List : ABJ International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis 2300 HI01-2 Industry Admitting Diagnosis 2300 HI Patient s HI*P>78701~ eason For Visit FHP Note: equired for Outpatient Visits 2300 HI01-1 Health Care List : AP International Classification of Diseases Clinical Modification (ICD-10-CM) Patient s eason for Visit 2300 HI01-2 Industry Patient eason For Visit Page 25

26 Loop Element Name Instructions & Examples equired/ 2300 HI02-1 Health Care List AP International Classification of Diseases Clinical Modification (ICD-10-CM) Patient s eason for Visit 2300 HI02-2 Industry Patient eason For Visit 2300 HI03-1 Health Care List AP International Classification of Diseases Clinical Modification (ICD-10-CM) Patient s eason for Visit 2300 HI03-2 Industry Patient eason For Visit 2300 HI External Cause Of Injury 2300 HI01-1 Health Care HI*ABN>E8660~ List : ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury (E-codes) 2300 HI01-2 Industry External Cause of Injury 2300 HI01-9 Yes/No Condition or esponse Present On Admission Indicator N No U Unknown W Not Applicable Y Yes 2300 HI02-1 Health Care List : ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury (E-codes) Page 26

27 Loop Element Name Instructions & Examples equired/ 2300 HI02-2 Industry External Cause of Injury 2300 HI02-9 Yes/No Condition or esponse Present On Admission Indicator N No U Unknown W Not Applicable Y Yes 2300 HI03-1 Health Care List : ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury (E-codes) 2300 HI03-2 Industry External Cause of Injury 2300 HI03-9 Yes/No Condition or esponse Present On Admission Indicator N No U Unknown W Not Applicable Y Yes 2300 HI04-1 Health Care List : ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury (E-codes) 2300 HI04-2 Industry External Cause of Injury 2300 HI04-9 Yes/No Condition or esponse Present On Admission Indicator N No U Unknown W Not Applicable Y Yes Page 27

28 Loop Element Name Instructions & Examples equired/ 2300 HI05-1 Health Care List : ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury (E-codes) 2300 HI05-2 Industry External Cause of Injury 2300 HI05-9 Yes/No Condition or esponse Present On Admission Indicator N No U Unknown W Not Applicable Y Yes 2300 HI06-1 Health Care List : ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury (E-codes) 2300 HI06-2 Industry External Cause of Injury 2300 HI06-9 Yes/No Condition or esponse Present On Admission Indicator N No U Unknown W Not Applicable Y Yes 2300 HI07-1 Health Care List : ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury (E-codes) 2300 HI07-2 Industry External Cause of Injury Page 28

29 Loop Element Name Instructions & Examples equired/ 2300 HI07-9 Yes/No Condition or esponse Present On Admission Indicator N No U Unknown W Not Applicable Y Yes 2300 HI08-1 Health Care List : ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury (E-codes) 2300 HI08-2 Industry External Cause of Injury 2300 HI08-9 Yes/No Condition or esponse Present On Admission Indicator N No U Unknown W Not Applicable Y Yes 2300 HI09-1 Health Care List : ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury (E-codes) 2300 HI09-2 Industry External Cause of Injury 2300 HI09-9 Yes/No Condition or esponse Present On Admission Indicator N No U Unknown W Not Applicable Y Yes 2300 HI10-1 Health Care List : ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury (E-codes) Page 29

30 Loop Element Name Instructions & Examples equired/ 2300 HI10-2 Industry External Cause of Injury 2300 HI10-9 Yes/No Condition or esponse Present On Admission Indicator N No U Unknown W Not Applicable Y Yes 2300 HI11-1 Health Care List : ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury (E-codes) 2300 HI11-2 Industry External Cause of Injury 2300 HI11-9 Yes/No Condition or esponse Present On Admission Indicator N No U Unknown W Not Applicable Y Yes 2300 HI12-1 Health Care List : ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury (E-codes) 2300 HI12-2 Industry External Cause of Injury 2300 HI12-9 Yes/No Condition Present On Admission Indicator or esponse N No U Unknown W Not Applicable Y Yes 2300 HI Diagnosis elated Group (DG) HI*D>123~ Page 30

31 Loop Element Name Instructions & Examples equired/ 2300 HI01-1 Health Care List : D Diagnosis elated Group (DG) CODE OUCE 229: Diagnosis elated Group Number (DG) 2300 HI01-2 Industry Diagnosis elated Group (DG) 2300 HI Other Diagnosis 2300 HI01-1 Health Care HI*ABF>4821>>>>>>>N*ABF>4821>>>>>>>N~ FHP Note: egment may be repeated once if there are more than twelve diagnoses to report in this category List : ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis 2300 HI01-2 Industry Other Diagnosis 2300 HI01-9 Yes/No Condition or esponse C is used to identify the diagnosis onset as it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not HI02-1 Health Care N No U Unknown W Not Applicable Y Yes List : ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis 2300 HI02-2 Industry Other Diagnosis Page 31

32 Loop Element Name Instructions & Examples equired/ 2300 HI02-9 Yes/No Condition C is used to identify the diagnosis onset as or esponse it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not HI03-1 Health Care N No U Unknown W Not Applicable Y Yes List : ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis 2300 HI03-2 Industry Other Diagnosis 2300 HI03-9 Yes/No Condition or esponse C is used to identify the diagnosis onset as it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not HI04-1 Health Care N No U Unknown W Not Applicable Y Yes List : ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis 2300 HI04-2 Industry Other Diagnosis Page 32

33 Loop Element Name Instructions & Examples equired/ 2300 HI04-9 Yes/No Condition C is used to identify the diagnosis onset as or esponse it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not HI05-1 Health Care N No U Unknown W Not Applicable Y Yes List : ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis 2300 HI05-2 Industry Other Diagnosis 2300 HI05-9 Yes/No Condition or esponse C is used to identify the diagnosis onset as it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not HI06-1 Health Care N No U Unknown W Not Applicable Y Yes List : ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis 2300 HI06-2 Industry Other Diagnosis Page 33

34 Loop Element Name Instructions & Examples equired/ 2300 HI06-9 Yes/No Condition C is used to identify the diagnosis onset as or esponse it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not HI07-1 Health Care N No U Unknown W Not Applicable Y Yes List : ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis 2300 HI07-2 Industry Other Diagnosis 2300 HI07-9 Yes/No Condition or esponse C is used to identify the diagnosis onset as it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not HI08-1 Health Care N No U Unknown W Not Applicable Y Yes List : ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis 2300 HI08-2 Industry Other Diagnosis Page 34

35 Loop Element Name Instructions & Examples equired/ 2300 HI08-9 Yes/No Condition C is used to identify the diagnosis onset as or esponse it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not HI09-1 Health Care N No U Unknown W Not Applicable Y Yes List : ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis 2300 HI09-2 Industry Other Diagnosis 2300 HI09-9 Yes/No Condition or esponse C is used to identify the diagnosis onset as it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not HI10-1 Health Care N No U Unknown W Not Applicable Y Yes List : ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis 2300 HI10-2 Industry Other Diagnosis Page 35

36 Loop Element Name Instructions & Examples equired/ 2300 HI10-9 Yes/No Condition C is used to identify the diagnosis onset as or esponse it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not HI11-1 Health Care N No U Unknown W Not Applicable Y Yes List : ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis 2300 HI11-2 Industry Other Diagnosis 2300 HI11-9 Yes/No Condition or esponse C is used to identify the diagnosis onset as it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not HI12-1 Health Care N No U Unknown W Not Applicable Y Yes List : ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis 2300 HI12-2 Industry Other Diagnosis Page 36

37 Loop Element Name Instructions & Examples equired/ 2300 HI12-9 Yes/No Condition C is used to identify the diagnosis onset as or esponse it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not HI Principal Procedure 2300 HI01-1 Health Care N No U Unknown W Not Applicable Y Yes HI*B>3121>D8> ~ FHP Note: equired on inpatient claims when a procedure was performed. List : BB International Classification of Diseases Clinical Modification (ICD-10-PC) Principal Procedure s CAH Advanced Billing Concepts (ABC) s 2300 HI01-2 Industry Principal Procedure 2300 HI01-3 Date Time Period Format 2300 HI01-4 Date Time Period Format 2300 HI Other Procedure D8 Date Expressed in Format CCYYMMDD Principal Procedure Date HI*BBQ:3614:D8: *BBQ:3723:D8: ~ FHP Note: egment may be repeated once if there are more than twelve diagnoses to report in this category Page 37

38 Loop Element Name Instructions & Examples equired/ 2300 HI01-1 Health Care BBQ - International Classification of Diseases Clinical Modification (ICD-10-PC) Principal Procedure s 2300 HI01-2 Industry Other Procedure 2300 HI01-3 Date Time Period Format 2300 HI01-4 Date Time Period Format 2300 HI02-1 Health Care D8 Date Expressed in Format CCYYMMDD Other Procedure Date BBQ - International Classification of Diseases Clinical Modification (ICD-10-PC) Principal Procedure s 2300 HI02-2 Industry Other Procedure 2300 HI02-3 Date Time Period Format 2300 HI02-4 Date Time Period Format 2300 HI03-1 Health Care D8 Date Expressed in Format CCYYMMDD Other Procedure Date BBQ - International Classification of Diseases Clinical Modification (ICD-10-PC) Principal Procedure s 2300 HI03-2 Industry Other Procedure 2300 HI03-3 Date Time Period D8 Date Expressed in Format CCYYMMDD Format 2300 HI03-4 Date Time Period Format Other Procedure Date 2300 HI04-1 Health Care BBQ - International Classification of Diseases Clinical Modification (ICD-10-PC) Principal Procedure s 2300 HI04-2 Industry Other Procedure 2300 HI04-3 Date Time Period Format D8 Date Expressed in Format CCYYMMDD Page 38

39 Loop Element Name Instructions & Examples equired/ 2300 HI04-4 Date Time Period Format Other Procedure Date 2300 HI05-1 Health Care BBQ - International Classification of Diseases Clinical Modification (ICD-10-PC) Principal Procedure s 2300 HI05-2 Industry Other Procedure 2300 HI05-3 Date Time Period Format 2300 HI05-4 Date Time Period Format 2300 HI06-1 Health Care D8 Date Expressed in Format CCYYMMDD Other Procedure Date BBQ - International Classification of Diseases Clinical Modification (ICD-10-PC) Principal Procedure s 2300 HI06-2 Industry Other Procedure 2300 HI06-3 Date Time Period Format 2300 HI06-4 Date Time Period Format 2300 HI07-1 Health Care D8 Date Expressed in Format CCYYMMDD Other Procedure Date BBQ - International Classification of Diseases Clinical Modification (ICD-10-PC) Principal Procedure s 2300 HI07-2 Industry Other Procedure 2300 HI07-3 Date Time Period D8 Date Expressed in Format CCYYMMDD Format 2300 HI07-4 Date Time Period Format Other Procedure Date 2300 HI08-1 Health Care BBQ - International Classification of Diseases Clinical Modification (ICD-10-PC) Principal Procedure s 2300 HI08-2 Industry Other Procedure Page 39

40 Loop Element Name Instructions & Examples equired/ 2300 HI08-3 Date Time Period D8 Date Expressed in Format CCYYMMDD Format 2300 HI08-4 Date Time Period Format Other Procedure Date 2300 HI09-1 Health Care BBQ - International Classification of Diseases Clinical Modification (ICD-10-PC) Principal Procedure s 2300 HI09-2 Industry Other Procedure 2300 HI09-3 Date Time Period Format 2300 HI09-4 Date Time Period Format 2300 HI10-1 Health Care D8 Date Expressed in Format CCYYMMDD Other Procedure Date BBQ - International Classification of Diseases Clinical Modification (ICD-10-PC) Principal Procedure s 2300 HI10-2 Industry Other Procedure 2300 HI10-3 Date Time Period Format 2300 HI10-4 Date Time Period Format 2300 HI11-1 Health Care D8 Date Expressed in Format CCYYMMDD Other Procedure Date BBQ - International Classification of Diseases Clinical Modification (ICD-10-PC) Principal Procedure s 2300 HI11-2 Industry Other Procedure 2300 HI11-3 Date Time Period D8 Date Expressed in Format CCYYMMDD Format 2300 HI11-4 Date Time Period Format Other Procedure Date Page 40

41 Loop Element Name Instructions & Examples equired/ 2300 HI12-1 Health Care BBQ - International Classification of Diseases Clinical Modification (ICD-10-PC) Principal Procedure s 2300 HI12-2 Industry Other Procedure 2300 HI12-3 Date Time Period Format 2300 HI12-4 Date Time Period Format 2300 HI Occurrence pan 2300 HI01-1 Health Care D8 Date Expressed in Format CCYYMMDD Other Procedure Date HI*BI>70>D8> *BI>74>D8> ~ List : BI Occurrence pan CODE OUCE 132: National Uniform Billing Committee (NUBC) s 2300 HI01-2 Industry Occurrence pan 2300 HI01-3 Date Time Period Format 2300 HI01-4 Date Time Period Format 2300 HI02-1 Health Care D8 Date Expressed in Format CCYYMMDD- CCYYMMDD Occurrence pan Date List : BI Occurrence pan CODE OUCE 132: National Uniform Billing Committee (NUBC) s 2300 HI02-2 Industry Occurrence pan 2300 HI02-3 Date Time Period Format 2300 HI02-4 Date Time Period Format 2300 HI03-1 Health Care D8 Date Expressed in Format CCYYMMDD- CCYYMMDD Occurrence pan Date List : BI Occurrence pan CODE OUCE 132: National Uniform Billing Committee (NUBC) s 2300 HI03-2 Industry Occurrence pan 2300 HI03-3 Date Time Period Format D8 Date Expressed in Format CCYYMMDD- CCYYMMDD Page 41

42 Loop Element Name Instructions & Examples equired/ 2300 HI03-4 Date Time Period Format Occurrence pan Date 2300 HI Occurrence 2300 HI01-1 Health Care HI*BH>70>D8> *BH>74>D8> ~ List : BH Occurrence CODE OUCE 132: National Uniform Billing Committee (NUBC) s 2300 HI01-2 Industry Occurrence 2300 HI01-3 Date Time Period D8 Date Expressed in Format CCYYMMDD Format 2300 HI01-4 Date Time Period Occurrence Date Format 2300 HI02-1 Health Care List : BH Occurrence CODE OUCE 132: National Uniform Billing Committee (NUBC) s 2300 HI02-2 Industry Occurrence 2300 HI02-3 Date Time Period Format 2300 HI02-4 Date Time Period Format 2300 HI03-1 Health Care D8 Date Expressed in Format CCYYMMDD Occurrence Date List : BH Occurrence CODE OUCE 132: National Uniform Billing Committee (NUBC) s 2300 HI03-2 Industry Occurrence 2300 HI03-3 Date Time Period Format 2300 HI03-4 Date Time Period Format 2300 HI Value 2300 HI01-1 Health Care D8 Date Expressed in Format CCYYMMDD Occurrence Date HI*BE>70>>199.99*BE>74>>420.01~ List : BE Value CODE OUCE 132: National Uniform Billing Committee (NUBC) s Page 42

43 Loop Element Name Instructions & Examples equired/ 2300 HI01-2 Industry Value 2300 HI01-5 Monetary Amount Value Amount 2300 HI02-1 Health Care List : BE Value CODE OUCE 132: National Uniform Billing Committee (NUBC) s 2300 HI02-2 Industry Value 2300 HI02-5 Monetary Amount Value Amount 2300 HI03-1 Health Care List : BE Value CODE OUCE 132: National Uniform Billing Committee (NUBC) s 2300 HI03-2 Industry Value 2300 HI03-5 Monetary Amount Value Amount 2300 HI Condition HI*BG>17*BG>67~ 2300 HI01-1 Health Care List : BG Condition CODE OUCE 132: National Uniform Billing Committee (NUBC) s 2300 HI01-2 Industry Condition 2300 HI02-1 Health Care List : BG Condition CODE OUCE 132: National Uniform Billing Committee (NUBC) s 2300 HI02-2 Industry Condition 2300 HI03-1 Health Care List : BG Condition CODE OUCE 132: National Uniform Billing Committee (NUBC) s 2300 HI03-2 Industry Condition 2300 HI Treatment HI*TC>A01*TC>A02~ Page 43

44 Loop Element Name Instructions & Examples equired/ 2300 HI01-1 Health Care List : TC Treatment s CODE OUCE 359: Treatment s 2300 HI01-2 Industry Treatment s 2300 HI02-1 Health Care List : TC Treatment s CODE OUCE 359: Treatment s 2300 HI02-2 Industry Treatment s 2300 HI03-1 Health Care List : TC Treatment s CODE OUCE 359: Treatment s 2300 HI03-2 Industry Treatment s 2310A NM1 Attending NM1*71*1*TONY WELL*L**XX* ~ Provider Name FHP Notes: equired when the claim contains any services other than non-scheduled transportation. NPI is required for all providers. Please note that if Attending Provider s NPI is not provided; Claim will be rejected by FHP. 2310A NM101 Entity Identifier 71 Attending Physician 2310A NM102 Entity Type 1 Person 2310A NM103 Name Last Attending Provider Last Name 2310A NM104 Name First Attending Provider First Name 2310A NM105 Name Middle Attending Provider Middle Name 2310A NM107 Name uffix Attending Provider Name uffix 2310A NM108 XX Centers for Medicare and Medicaid ervices National Provider Identifier 2310A NM109 Attending Provider Identifier 2310A PV Attending PV*PE*PXC*261D0000X~ Provider pecialty 2310A PV01 Provider AT Attending 2310A PV02 eference PXC Health Care Provider Taxonomy Page 44

45 Loop Element Name Instructions & Examples equired/ 2310A PV03 eference Provider Taxonomy 2310A EF Attending EF*1G*A54321~ Provider econdary 2310A EF01 eference 0B tate License Number 1G Provider UPIN Number 2310A EF02 eference Attending Provider econdary Identifier 2310B NM1 Operating Physician Name 2310B NM101 Entity Identifier 2310B NM102 Entity Type NM1*72*1*TONY WELL*L**XX* ~ FHP Notes: equired when a surgical procedure is listed on the claim. NPI is required for all providers. Please note that if Operating Provider s NPI is not provided; Claim will be rejected by FHP. 72 Operating Physician 1 Person 2310B NM103 Name Last Operating Physician Last Name 2310B NM104 Name First Operating Physician First Name 2310B NM105 Name Middle Operating Physician Middle Name 2310B NM107 Name uffix Operating Physician Name uffix 2310B NM108 XX Centers for Medicare and Medicaid ervices National Provider Identifier 2310B NM109 Operating Physician Identifier 2310B EF Operating Physician econdary 2310B EF01 eference 2310B EF02 eference EF*1G*A54321~ 0B tate License Number 1G Provider UPIN Number Operating Physician econdary Identifier Page 45

46 Loop Element Name Instructions & Examples equired/ 2310C NM1 Other Operating NM1*ZZ*1*TONY WELL*L**XX* ~ Physician Name FHP Notes: equired when another operating physician is involved. NPI is required for all providers. Please note that if Other Operating Provider s NPI is not provided; Claim will be rejected by FHP. 2310C NM101 Entity Identifier ZZ Mutually Defined 2310C NM102 Entity Type 1 Person 2310C NM103 Name Last Other Operating Physician Last Name 2310C NM104 Name First Other Operating Physician First Name 2310C NM105 Name Middle Other Operating Physician Middle Name 2310C NM107 Name uffix Other Operating Physician Name uffix 2310C NM108 XX Centers for Medicare and Medicaid ervices National Provider Identifier 2310C NM109 Other Operating Physician Identifier 2310C EF Other Operating Physician econdary 2310C EF01 eference 2310C EF02 eference 2310D NM1 endering Provider Name 2310D NM101 Entity Identifier 2310D NM102 Entity Type EF*1G*A54321~ 0B tate License Number 1G Provider UPIN Number Other Operating Physician econdary Identifier NM1*82*1*TONY WELL*L**XX* ~ FHP Notes: equired when the rendering provider is different than the attending provider. NPI is required for all providers. Please note that if endering Provider s NPI is not provided; Claim will be rejected by FHP. 82 endering Provider 1 Person 2310D NM103 Name Last endering Provider Last Name 2310D NM104 Name First endering Provider First Name 2310D NM105 Name Middle endering Provider Middle Name 2310D NM107 Name uffix endering Provider Name uffix Page 46

47 Loop Element Name Instructions & Examples equired/ 2310D NM108 XX Centers for Medicare and Medicaid ervices Provider Identifier 2310D NM109 endering Provider Primary Identifier 2310D EF endering Provider econdary EF*1G*A54321~ 2310D EF01 eference 2310D EF02 eference 2310E NM1 ervice Facility Location Name 2310E NM101 Entity Identifier 2310E NM102 Entity Type 0B tate License Number 1G Provider UPIN Number endering Provider econdary Identifier NM1*77*2*TONY WELL HLTH CNT***XX* ~ FHP Notes: equired if different than the Billing Provider. NPI is required for all providers. Please note that if ervice Facility s NPI is not provided; Claim will be rejected by FHP. 77 ervice Location 2 Non-Person 2310E NM103 Name Last ervice Facility Name 2310E NM108 XX Centers for Medicare and Medicaid ervices Provider Identifier 2310E NM109 Facility Primary Identifier 2310E N3 ervice Facility N3*1022 5D AVE~ Address 2310E N301 Address ervice Facility Address Line 2310E N302 Address Additional Address Line 2310E N4 ervice Facility N4*AN FANCICO*CA* ~ City, tate, Zip 2310E N401 City Name ervice Facility City Name 2310E N402 tate or Province ervice Facility tate 2310E N403 Postal ervice Facility Postal Page 47

48 Loop Element Name Instructions & Examples equired/ 2310E EF ervice Facility EF*G2*A54321~ Location econdary 2310E EF01 eference 0B tate License Number G2 Provider Commercial Number 2310E EF02 eference Laboratory or Facility econdary Identifier 2310F NM1 eferring Provider Name 2310F NM101 Entity Identifier 2310F NM102 Entity Type NM1*DN*1*MAA*LEE****XX* ~ FHP Notes: equired on an outpatient claim when the referring provider is different from the attending provider. NPI is required for all providers. Please note that if eferring Provider s NPI is not provided; Claim will be rejected by FHP. DN eferring Provider P3 Primary Care Provider 1 Person 2010F NM103 Name Last eferring Provider Name 2010F NM104 Name First eferring Provider First Name 2010F NM105 Name Middle eferring Provider Middle Name 2010F NM107 Name uffix eferring Provider Name uffix 2310F NM108 XX Centers for Medicare and Medicaid ervices Provider Identifier 2310F NM109 ubscriber Primary Identifier 2310F EF eferring EF*G2*A54321~ Provider econdary 2310F EF01 eference 0B tate License Number G1 Provider UPIN Number 2310F EF02 eference eferring Provider econdary Identifier 2320 B Other ubscriber B**18*******CI~ FHP Note: The 2320 COB loop is required for encounters and claims when part or all was already paid by another payer. Page 48

49 Loop Element Name Instructions & Examples equired/ 2320 B01 Payer P Primary esponsibility equence Number econdary T Tertiary U Unknown 2320 B02 Individual 18 Primary elationship 2320 B03 eference Insured Group or Policy Number 2320 CA Claim Level Adjustments CA*P*1*10.00~ 2320 CA01 Claim Adjustment Group CO Contractual Obligations C Corrections and eversals OA Other Adjustments PI Payer Initiated eductions P Patient esponsibility 2320 CA02 Claims Adjustment Adjustment eason eason 2320 CA03 Monetary Amount Adjustment Amount 2320 CA04 Quantity Adjustment Quantity 2320 CA05 Claims Adjustment Adjustment eason eason 2320 CA06 Monetary Amount Adjustment Amount 2320 CA07 Quantity Adjustment Quantity 2320 CA08 Claims Adjustment Adjustment eason eason 2320 CA09 Monetary Amount Adjustment Amount 2320 CA10 Quantity Adjustment Quantity 2320 CA11 Claims Adjustment Adjustment eason eason 2320 CA12 Monetary Amount Adjustment Amount 2320 CA13 Quantity Adjustment Quantity 2320 CA14 Claims Adjustment Adjustment eason eason 2320 CA15 Monetary Amount Adjustment Amount 2320 CA16 Quantity Adjustment Quantity 2320 CA17 Claims Adjustment Adjustment eason eason 2320 CA18 Monetary Amount Adjustment Amount 2320 CA19 Quantity Adjustment Quantity Page 49

50 Loop Element Name Instructions & Examples equired/ 2320 AMT Coordination Of AMT*D*411.10~ Benefits (COB) Payer Paid Amount 2320 AMT01 Amount D Payer Amount Paid 2320 AMT02 Monetary Amount Payer Paid Amount 2320 AMT emaining AMT*EAF*210.11~ Patient Liability 2320 AMT01 Amount EAF Amount Owed 2320 AMT02 Monetary Amount emaining Patient Liability 2320 AMT Coordination Of AMT*A8*30.25~ Benefits (COB) Total Non- Covered Amount 2320 AMT01 Amount A8 Non-covered Charges - Actual 2320 AMT02 Monetary Amount Non-Covered Charge Amount 2320 OI Other Insurance Coverage 2320 OI03 Yes/No Condition or esponse 2320 OI06 elease of 2320 MIA Inpatient Adjudication OI***Y***Y~ FHP Note: OI egment required when Other ubscriber Loop included This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. Y Yes N No W Not Applicable I Informed Consent to elease Medical for Conditions or Diagnoses egulated by Federal tatutes Y Yes, Provider has a igned tatement Permitting elease of Medical Billing Data elated to a Claim MIA*1*** *MA01***************21 ***MA25~ 2320 MIA01 Quantity Covered days or visits count 2320 MOA Outpatient Adjudication MOA***A4~ Page 50

51 Loop Element Name Instructions & Examples equired/ 2320 MOA01 Percent eimbursement ate 2320 MOA02 Monetary Amount HCPC Payable Amount 2330A NM1 Other NM1*IL*1*DOE*JOHN*T**J*MI*123456~ ubscriber FHP Note: The 2330A loop is required when the 2320 COB loop is included. 2330A NM101 Entity IL - Insured or ubscriber 2330A NM102 Entity Type 2330A NM103 Last name or Organization name 1 - Person 2 - Non-Person Entity ubscriber Last Name 2330A NM104 First name ubscriber First Name 2330A NM105 Middle name ubscriber Middle Name 2330A NM108 MI 2330A NM109 code Member Number 2330B NM1 Other Payer Name 2330B NM101 Entity Identifier 2330B NM102 Entity Type 2330B NM103 Organization Name 2330B NM B NM109 NM1*P*2*ABC INUANCE CO*****PI* ~ FHP Note: The 2330B loop is required when the 2320 COB loop is included. P Payer 2 Non-Person Entity Other Payer Organization Name PI Payer XV CM Plan ID Other Payer Primary Identifier Page 51

52 Claim Line Level Detail Loop Element Name Instructions & Examples equired/ 2400 LX ervice Line Number LX*1~ LX functions as a line counter 2400 LX01 Assigned Number The ervice Line LX segment must begin with one and is incremented by one for each additional service line of a claim V2 Institutional ervice Line V2*0300*HC>81099*73.42*UN*1~ 2400 V201-1 Product/ervice ID 2400 V202-1 Product/ervice ID 2400 V202-2 Product/ervice ID 2400 V202-3 Procedure Modifier 2400 V202-4 Procedure Modifier 2400 V202-5 Procedure Modifier 2400 V202-6 Procedure Modifier ervice Line evenue ee ource 132: National Uniform Billing Committee (NUBC) s. HC Health Care Financing Administration Common Procedural Coding ystem (HCPC) s CODE OUCE 130: Healthcare Common Procedural Coding ystem Procedure Identifies special circumstances related to the performance of the service Identifies special circumstances related to the performance of the service Identifies special circumstances related to the performance of the service Identifies special circumstances related to the performance of the service 2400 V203 Monetary Amount Line Item Charge Amount 2400 V204 Unit or Basis for DA Days Measurement UN Unit 2400 V205 Quantity ervice Unit Count 2400 DTP ervice Date DTP*472*D8* ~ DTP*472*D8* ~ 2400 DTP01 Date/Time 2400 DTP02 Date Time Period Format 472 ervice D8 Date Expressed in Format CCYYMMDD D8 ange of Dates Expressed in Format CCYYMMDD-CCYYMMDD 2400 DTP03 Date Time Period ervice Date 2400 EF Line Item EF*6*12345~ Control Number Page 52

53 Loop Element Name Instructions & Examples equired/ 2400 EF01 eference 6 Provider Control Number 2400 EF02 eference Line Item Control Number 2410 LIN Drug LIN**N4* ~ 2410 LIN02 Product/ervice N4 National Drug in Format ID 2410 LIN03 Product/ervice National Drug or Universal Product Number ID 2410 CTP Drug Quantity CTP****2*UN~ 2410 CTP04 Quantity National Drug Unit Count 2410 CTP05-1 Unit or Basis for Measurement 2410 EF Prescription Or Compound Drug Association Number 2410 EF01 eference 2410 EF02 eference 2420A NM1 OPEATING PHYICIAN NAME 2420A NM101 Entity Identifier 2420A NM102 Entity Type F2 International Unit G Gram ME Milligram ML Milliliter EF*XZ*123456~ VY Link sequence Number XZ Pharmacy prescription Number Prescription Number NM1*ZZ*1*JONE*JOHN***XX* ~ FHP Notes: equired when different from the attending provider and when different from the rendering provider at the claim level. NPI is required for all providers. Please note that if Operating Provider s NPI is not provided; Claim will be rejected by FHP. 72 Mutually Defined "1" - Person 2420A NM103 Name Last Operating Physician Last Name 2420A NM104 Name First Operating Physician First Name 2420A NM105 Name Middle Operating Physician Middle Name or Initial 2420A NM107 Name uffix Operating Physician Name uffix Page 53

54 Loop Element Name Instructions & Examples equired/ 2420A NM A NM A EF OPEATING PHYICIAN ECONDAY IDENTIFICATION 2420A EF01 eference 2420A EF02 eference 2420A EF04-1 eference 2420A EF04-2 eference 2420B NM1 OTHE OPEATING PHYICIAN NAME 2420B NM101 Entity Identifier 2420B NM102 Entity Type XX Centers for Medicare and Medicaid ervices National Provider Identifier Operating Physician Identifier EFG2*12345~ OB tate License Number 1G Provider UPN UPINs must be formatted as either X99999 or XXX999. Operating Physician econdary Identifier eference 2U Payer Number Other Payer Primary Identifier NM1*ZZ*1*JONE*JOHN***XX* ~ FHP Notes: equired when different from the attending provider and when different from the rendering provider at the claim level. NPI is required for all providers. Please note that if Other Operating Provider s NPI is not provided; Claim will be rejected by FHP. ZZ Mutually Defined "1" - Person 2420B NM103 Name Last Other Operating Physician Last Name 2420B NM104 Name First Other Operating Physician First Name 2420B NM105 Name Middle Other Operating Physician Middle Name or Initial 2420B NM107 Name uffix Other Operating Physician Name uffix 2420B NM B NM B EF OTHE OPEATING PHYICIAN ECONDAY IDENTIFICATION XX Centers for Medicare and Medicaid ervices National Provider Identifier Other Operating Physician Identifier EFG2*12345~ Page 54

55 Loop Element Name Instructions & Examples equired/ 2420B EF01 eference 2420B EF02 eference 2420B EF04-1 eference 2420B EF04-2 eference 2420C NM1 endering Provider Name 2420C NM101 Entity Identifier 2420C NM102 Entity Type OB Provider Commercial Number 1G Location Number "G2" Provider Commercial Number "LU" Location Number Other Operating Physician econdary Identifier eference 2U Payer Other Payer Primary Identifier NM1*82*1*TONY WELL*L**XX* ~ FHP Notes: equired when different from the attending provider and when different from the rendering provider at the claim level. NPI is required for all providers. Please note that if endering Provider s NPI is not provided; Claim will be rejected by FHP. 82 endering Provider 1 Person 2420C NM103 Name Last endering Provider Name 2420C NM104 Name First endering Provider First Name 2420C NM105 Name Middle endering Provider Middle Name 2420C NM107 Name uffix endering Provider Name uffix 2420C NM108 XX Centers for Medicare and Medicaid ervices Provider Identifier 2420C NM109 endering Provider Identifier 2420C EF endering Provider econdary 2420C EF01 eference 2420C EF02 eference 2420C EF04-1 eference 2420C EF04-2 eference EF*G2*12345 OB Provider Commercial Number 1G Location Number "G2" Provider Commercial Number "LU" Location Number endering Provider econdary Identifier eference 2U Payer Other Payer Primary Identifier Page 55

56 Loop Element Name Instructions & Examples equired/ 2420D NM1 eferring NM1*DN*1*MAA*LEE****XX* ~ Provider Name FHP Notes: equired when different from the attending provider and when different from the Attending provider at the claim level. NPI is required for all providers. Please note that if eferring Provider s NPI is not provided; Claim will be rejected by FHP. 2420D NM101 Entity Identifier DN eferring Provider 2420D NM102 Entity Type 1 Person 2420D NM103 Name Last eferring Provider Name 2420D NM104 Name First eferring Provider First Name 2420D NM105 Name Middle eferring Provider Middle Name 2420D NM107 Name uffix eferring Provider Name uffix 2420D NM108 XX Centers for Medicare and Medicaid ervices Provider Identifier 2420D NM109 ubscriber Primary Identifier 2420D EF eferring Provider econdary 2420D EF01 eference EF*G2*A54321~ OB Provider Commercial Number 1G Location Number "G2" Provider Commercial Number 2420D EF02 eference eferring Provider econdary Identifier 2430 VD Line VD*43*55.00*HC>84550**3~ Adjudication 2430 VD01 Other Payer Primary Identifier 2430 VD02 Monetary Amount 2430 VD03-1 Composite Medical Procedure Identifier 2430 VD03-2 Product/ervice ID 2430 VD03-3 Procedure Modifier Product/ervice ID HC Health Care Financing Administration Common Procedural Coding ystem (HCPC) s Procedure Identifies pecial Circumstances related to the performance of the service Page 56

57 Loop Element Name Instructions & Examples equired/ 2430 VD03-4 Procedure Modifier 2430 VD03-5 Procedure Modifier Identifies pecial Circumstances related to the performance of the service Identifies pecial Circumstances related to the performance of the service 2430 VD03-6 Procedure Identifies pecial Circumstances related to the Modifier performance of the service 2430 VD05 Quantity Paid ervice Unit Count 2430 CA Line Adjustments CA*P*1*10.00~ 2430 CA01 Line Adjustment Group CO Contractual Obligations C Corrections and eversals OA Other Adjustments PI Payer Initiated eductions P Patient esponsibility Adjustment eason 2430 CA02 Line Adjustment eason 2430 CA03 Monetary Amount Adjustment Amount 2430 CA04 Quantity Adjustment Quantity 2430 CA05 Line Adjustment Adjustment eason eason 2430 CA06 Monetary Amount Adjustment Amount 2430 CA07 Quantity Adjustment Quantity 2430 CA08 Line Adjustment Adjustment eason eason 2430 CA09 Monetary Amount Adjustment Amount 2430 CA10 Quantity Adjustment Quantity 2430 CA11 Line Adjustment Adjustment eason eason 2430 CA12 Monetary Amount Adjustment Amount 2430 CA13 Quantity Adjustment Quantity 2430 CA14 Line Adjustment Adjustment eason eason 2430 CA15 Monetary Amount Adjustment Amount 2430 CA16 Quantity Adjustment Quantity 2430 CA17 Line Adjustment Adjustment eason eason 2430 CA18 Monetary Amount Adjustment Amount 2430 CA19 Quantity Adjustment Quantity 2430 DTP Line Check Or DTP*573*D8* ~ emittance Date FHP Note: equired when Loop 2430 is included Page 57

58 Loop Element Name Instructions & Examples equired/ 2430 DTP01 Date/Time 2430 DTP02 Date Time Period Format 2430 DTP03 Date Time Period 573 Date Claim Paid D8 Date Expressed in Format CCYYMMDD Adjudication or Payment Date Page 58

59 File Trailers Loop Element Name Instructions & Examples equired/ E E01 E02 GE GE01 GE02 IEA IEA01 IEA02 Transaction et Trailer Number of Included egments Transaction et Control Number Functional Group Trailer Number of Transaction ets Included Group Control Number Interchange Control Trailer Number of Included Functional Groups Interchange Control Number OTHE INFOMATION E*55*0001~ Transaction egment Count E02 must be identical to T02 G*1*1~ The following are standard field delimiters: Total number of transaction sets included in the functional group GE02 must be identical to G06 IEA*1* ~ Total number of functional groups included in an interchange IEA92 must be identical to IA13 Delimiter Delimiter Type * Data Element eparator > ub-element eparator ~ egment Terminator ICD-10 Diagnosis s ubmitters must adhere to the ICD-10 compliance date, any encounters/claims submitted for a date of service on or after October 1 st 2015 must use ICD-10 diagnosis codes otherwise the encounter/claim will be denied. Encounters/claims submitted for a date of service before October 1 st 2015 must continue to use ICD-9 diagnosis codes otherwise the encounter/claim will be denied. Page 59

60 837 Health Care Claim: Institutional HIPAA Companion Guide X223A2 Appendix A ample Claim Data PIMAY PAYE UBCIBE: John T Doe UBCIBE ADDE: 125 City Avenue, Centerville, PA EX: M DOB: 11/11/1926 MEDICAE INUANCE ID#: A PAYE ID #: PATIENT: ame as Primary ubscriber DETINATION PAYE: Health Plan UBMITTE: Jones Hospital EDI#: ECEIVE: Health Plan EDI #: BILLING POVIDE: Jones Hospital NPI: TIN: MEDICAE POVIDE: # ADDE: 225 Main treet Barkley Building, Centerville, PA ATTENDING PHYICIAN: John J Jones UPIN #: B99937 PATIENT ACCOUNT NUMBE: Q DATE OF ADMIION: 09/11/96 TATEMENT PEIOD DATE: 09/11/96-09/11/96 PLACE OF EVICE: Inpatient Hospital TYPE OF Bill: 141 Occurrence s and Dates: A1 11/11/26 A2 11/01/91 B1 11/11/26 B2 01/01/87 Condition s: 09 Value s: A2 $15.31 PINCIPAL DIAGNOI CODE: ECONDAY DIAGNOI CODE: NUMBE OF COVEED DAY: 1 EVICE: INTITUTIONAL EVICE ENDEED: EVENUE CODE: 0305 HCPC Procedure : Unit: 1 Price $13.39 EVENUE CODE: 0730 HCPC Procedure : Unit: 1 Price: $76.54 TOTAL CHAGE: $89.93 FHP, Version 2.1 Final version, last updated 7/01/2014 Page 60

61 837 Health Care Claim: Institutional HIPAA Companion Guide X223A2 ample egments 1 TANACTION ET HEADE T*837*987654*005010X223~ 2 BHT BEGINNING OF HIEACHICAL TANACTION BHT*0019*00*0123* *0932*CH~ A UBMITTE NAME NM1 UBMITTE NAME NM1*41*2*JONE HOPITAL*****46*12345~ 4 PE UBMITTE EDI CONTACT INFOMATION PE*IC*JANE DOE*TE* ~ B ECEIVE NAME NM1 ECEIVE NAME NM1*40*2*Health Plan*****46*00120~ A BILLING POVIDE HL BILLING POVIDE HIEACHICAL LEVEL HL*1**20*1~ 7 PV BILLING POVIDE PECIALTY PV*BI*PXC*203BA0200N~ AA BILLING POVIDE NAME NM1 BILLING POVIDE NAME INCLUDING NATIONAL POVIDE ID N3 BILLING POVIDE ADDE NM1*85*2*JONE HOPITAL*****XX* ~ N3*225 MAIN TEET BAKLEY BUILDING~ 10 N4 BILLING POVIDE LOCATION N4*CENTEVILLE*PA*17111~ 11 EF BILLING POVIDE TAX IDENTIFICATION NUMBE EF*EI* ~ B UBCIBE HL LOOP HL UBCIBE HIEACHICAL LEVEL HL*2*1*22*0~ FHP, Version 2.1 Final version, last updated 7/01/2014 Page 61

62 837 Health Care Claim: Institutional HIPAA Companion Guide X223A2 13 B UBCIBE INFOMATION B*P*18*******MB~ BA UBCIBE NAME LOOP NM1 UBCIBE NAME NM1*IL*1*DOE*JOHN*T***MI* A~ 15 N3 UBCIBE ADDE N3*125 CITY AVENUE~ 16 N4 UBCIBE LOCATION N4*CENTEVILLE*PA*17111~ 17 DMG UBCIBE DEMOGAPHIC INFOMATION DMG*D8* *M~ BB PAYE NAME LOOP NM1 PAYE NAME NM1*P*2*MEDICAE B*****PI*00435~ 19 EF BILLING POVIDE ECONDAY IDENTIFICATION EF*G2*330127~ CLAIM INFOMATION CLM CLAIM LEVEL INFOMATION CLM*756048Q*89.93***14>A>1*Y*A*Y*Y~ 21 DTP TATEMENT DATE DTP*434*D8* ~ 22 CL1 INTITUTIONAL CLAIM CODE CL1*3**01~ 23 HI PINCIPAL DIAGNOI CODE HI*ABK>3669~ 24 HI OTHE DIAGNOI INFOMATION HI*ABF>4019*ABF>79431~ 25 HI OCCUENCE INFOMATION HI*BH>A1>D8> *BH>A2>D8> *BH>B 1>D8> *BH>B2>D8> ~ 26 HI VALUE INFOMATION HI*BE>A2>>>15.31~ FHP, Version 2.1 Final version, last updated 7/01/2014 Page 62

63 837 Health Care Claim: Institutional HIPAA Companion Guide X223A2 27 HI CONDITION INFOMATION HI*BG>09~ A ATTENDING POVIDE NAME NM1 ATTENDING POVIDE NM1*71*1*JONE*JOHN*J~ 29 EF ATTENDING POVIDE ECONDAY IDENTIFICATION EF*1G*B99937~ OTHE UBCIBE INFOMATION B OTHE UBCIBE INFOMATION B**01*351630*TATE TEACHE*****CI~ 31 DMG OTHE UBCIBE DEMOGAPHIC INFOMATION DMG*D8* *F~ 32 OI OTHE INUANCE COVEAGE INFOMATION OI***Y***Y~ EVICE LINE LX EVICE LINE COUNTE LX*1~ 34 V2 INTITUTIONAL EVICE V2*0305*HC>85025*13.39*UN*1~ 35 DTP DATE - EVICE DATE DTP*472*D8* ~ EVICE LINE LX EVICE LINE COUNTE LX*2~ 37 V2 INTITUTIONAL EVICE V2*0730*HC>93005*76.54*UN*3~ 38 DTP DATE - EVICE DATE DTP*472*D8* ~ 39 TAILE E TANACTION ET TAILE E*43*987654~ FHP, Version 2.1 Final version, last updated 7/01/2014 Page 63

64 837 Health Care Claim: Institutional HIPAA Companion Guide X223A2 ample Transaction et T*837*987654*005010X223~ BHT*0019*00*0123* *0932*CH~ NM1*41*2*JONE HOPITAL*****46*12345~ PE*IC*JANE DOE*TE* ~ NM1*40*2*Health Plan*****46*00120~ HL*1**20*1~ PV*BI*PXC*203BA0200N~ NM1*85*2*JONE HOPITAL*****XX* ~ N3*225 MAIN TEET BAKLEY BUILDING~ N4*CENTEVILLE*PA*17111~ EF*EI* ~ HL*2*1*22*0~ B*P*18*******MB~ NM1*IL*1*DOE*JOHN*T***MI* A~ N3*125 CITY AVENUE~ N4*CENTEVILLE*PA*17111~ DMG*D8* *M~ NM1*P*2*MEDICAE B*****PI*00435~ EF*G2*330127~ CLM*756048Q*89.93***14>A>1*Y*A*Y*Y~ DTP*434*D8* ~ CL1*3**01~ HI*ABK>3669~ HI*ABF>4019*ABF>7943~ HI*BH>A1>D8> *BH>A2>D8> *BH>B1>D8> *BH>B2>D8 > ~ HI*BE>A2>>>15.31~ HI*BG>09~ NM1*71*1*JONE*JOHN*J~ EF*1G*B99937~ B**01*351630*TATE TEACHE*****CI~ DMG*D8* *F~ OI***Y***Y~ LX*1~ V2*0305*HC>85025*13.39*UN*1~ DTP*472*D8* ~ LX*2~ V2*0730*HC>93005*76.54*UN*3~ DTP*472*D8* ~ E*43*987654~ FHP, Version 2.1 Final version, last updated 7/01/2014 Page 64

65 837 Health Care Claim: Institutional HIPAA Companion Guide X223A2 Appendix B HCPC s and NDC Equivalents This web address may be used to view HCPC codes and their NDC code equivalents: /index.html Click on the NDC/HCPC Crosswalk Files Choose the latest year for the most up-to-date crosswalk Here is a sample: NDC NDC Mod HCPC HCPC Mod elationship tart Date elationship End Date HCPC Description NDC Label J0130 1/1/ /99/ J2941 3/1/ /99/ J2941 1/1/2002 2/14/2012 INJECTION ABCIXIMAB, 10 MG INJECTION, OMATOPIN, 1 MG INJECTION, OMATOPIN, 1 MG EOPO (VIAL) 2 MG/ML HUMATOPE (WITH TEILE DILUENT) 5 MG HUMATOPE (W/DILUENT) 5 MG J9201 1/1/ /99/ Q J9201 Q 1/28/ /99/ J9201 1/1/ /99/9999 INJECTION, GEMCITABINE HYDOCHLOIDE, 200 MG INJECTION, GEMCITABINE HYDOCHLOIDE, 200 MG INJECTION, GEMCITABINE HYDOCHLOIDE, 200 MG GEMZA (VIAL) 200 MG GEMZA (VIAL) 200 MG GEMZA (VIAL) 1 GM FHP, Version 2.1 Final version, last updated 7/01/2014 Page 65