Using the 837 Institutional Data Mapping Document

Transcription

1 Using the 837 Institutional Data ping Document The "Complete" tab of this spreadsheet represents all data elements included in an 837 file submission. The "Abridged" tab displays only those data elements pulled from for the 837 file submission. Column Heading Explanation Logic X-Ref to Reference to row number in the ADG master mappings document. numbers refer to the ASC X12N Insurance Subcommittee Implementation Guide published by the Washington Publishing Company at Specific on the page cited in previous column. Description Desciption in HIPAA publication Column Name Name of column in the intermediate table that is created when Provider maps the user's s to HIPAA s in preparation for extraction by HIPAA Engine. Name of the window in which the targeted data is pulled from. Title of data field in corresponding window. Required? Indicates whether the data is required by the HIPAA standard. R = Required RV = Required and Validated = Conditional Validation based on other data elements Description from Global to HIPAA? Logic used to extract data from tables in Provider. Yellow highlighting indicates Assumptions included in the standard that users should take into account. Description from HIPAA specification Indicates whether users will need to map existing global s to HIPAA set.

2 HIPAA Definitions HIPAA Term* Provider Equivalent Definition Billing / Pay to Provider Billing / Pay to Provider Organization providing the service Payer Name Destination Payor Entity receiving a claim for reimbursement Other Payer n-destination Payor Other payors associated with a patient, but not receiving the claim Rendering Clinician Clinician Role listed on a Clinician providing the service Clinical Transaction Referring Clinician Referring Clinician list on a Clinician referring the patient for service Clinical Transaction Patient Patient Person receiving service * See the ASC X12N Insurance Subcommittee Implementation Guide style guide for discusstion of the usage and spelling of termsin HIPAA standards, Transaction set: Business grouping of data (e.g. ASC-X12 837Institutional) Loops: Groups of semantically related segments (e.g. subscriber information) Segment: Group of logically related data (e.g. subscriber) : The smallest named unit of information (e.g. subscriber s name, address, city/state/zip)

3 Askesis Development Group 837 Institutional Data ping Complete version represents all elements included in file submission X-Ref to Description Column Name definitions of Global to HIPAA? s to a HIPAA Header 1 56 ST02 Transaction Set Control Number 2 58 BHT02 Transaction Set Purpose 3 58 BHT03 Originator Application Transaction Identifier 4 58 BHT04 Transaction Set Creation Date 5 58 BHT05 Transaction Set Creation Time 6 59 BHT06 Claim or Encounter Identifier 7 60 REF02 Transmission Type trans_set_control_no_header N/A N/A R Sequential number starting at ' ' trans_set_purpose_ N/A N/A R Always '00' 00 = Original appl_trans_id N/A N/A R Populated with the date and time stamp from when the file was created. trans_creation_date N/A N/A R Current date in the format of 'ccyymmdd'. trans_creation_time N/A N/A R Current time in the format of 'hhmm'. encounter_id N/A N/A R Always 'CH' CH = Chargeable trans_type_ Configuration 837USAGE_IND R 2 Configuration options need to be set for this: 837USAGE_IND and 837I_TRANS_TYPE_CODE. When in Production, 837USAGE_IND should be set to P and the TRANS_TYPE_CODE should be set to 00401X096A1. When in Testing, 837USAGE_IND should be set to 'T' and the TRANS_TYPE_CODE should be set to 00A1401X096DA NM102 Entity Type Qualifier submitter_entity_qualifier N/A N/A R 2 2 = n-person Entity

4 Description Column Name Global to HIPAA? definitions of s to a HIPAA 9 62 NM103 Submitter Last or Organization Name NM109 Submitter Identifier submitter_id Global Sub / Coverage Plan submitter_lname Institution Name RV The first 35 characters of the Institution Name Sub Name / Electronic Claims Type RV Global Sub Name where category = 'Claims ping' and = 'Submitter ' and sub matches the Electronic Claims Type entered in the Coverage Plan window PER02 Submitter Contact Name PER03 Communication Number Qualifier PER04 Communication Number PER05 Communication Number Qualifier PER06 Communication Number submitter_contact_name Institution Name R Institution Name submitter_comm_no_1_qualifier Institution Telephone 'TE' where telephone type = Office (Global OP) submitter_comm_no_1 Institution Telephone R Telephone Number submitter_comm_no_2_qualifier Institution Telephone 'FX' where telephone type = Fax (Global BF) submitter_comm_no_2 Institution Telephone Fax Number NM103 Receiver Name receiver_lname Coverage Plan Plan Name RV The first 35 characters of Coverage Plan Name NM109 Receiver Primary Identifier receiver_primary_id Global Sub / Coverage Plan Sub Name / Electronic Claims Type RV Global Sub Name where category = 'Claims ping' and = 'Receiver ' and sub matches the Electronic Claims Type entered in the Coverage Plan window TE = Telephone FX = Fax Loop 2010AA - Billing Provider Name NM102 Billing Provider Entity Type Qualifier billing_provider_type_qualifier R Always 2 2 = n-person Entity

5 Description Column Name Global to HIPAA? definitions of s to a HIPAA NM103 Billing Provider Last or Organizational Name NM108 Identification Qualifier NM109 Billing Provider Identifier billing_provider_lname Protocol, Program, Service, Clinic or Institution Protocol Name, Program Name, Service Name, Clinic Name or Institution Name RV Based on the CSPP level or Institution where the Tax Id is located, populate the first 30 characters of either Protocol Name, Program Name, Services Name, Clinic Name or Institution Name billing_provider_id_qualifier R = Employer's Identification Number billing_provider_id Protocol, Tax RV Tax Program, Service, Clinic or Institution N301 Billing Provider Address Line N302 Billing Provider Address Line N401 Billing Provider City Name billing_provider_addr_1 billing_provider_addr_2 billing_provider_city Protocol, Program, Service, Clinic or Institution Protocol, Address 2 Program, Service, Clinic or Institution Protocol, Program, Service, Clinic or Institution Address 1 RV Based on the CSPP level or Institution where the Tax Id is located, select the Billing Address (BI global ). If there is not a Billing Address for the Institution, then Institution Address Based on the CSPP level or Institution where the Tax Id is located, select the Billing Address (BI global ). If there is not a Billing Address for the Institution, then Institution Address. City RV Based on the CSPP level or Institution where the Tax Id is located, select the Billing Address (BI global ). If there is not a Billing Address for the Institution, then Institution Address

6 Description Column Name Global to HIPAA? definitions of s to a HIPAA N402 Billing Provider State or Province N403 Billing Provider Postal Zone or ZIP REF01 Reference Identification Qualifier REF02 Billing Provider Additional Identifier PER02 Billing Provider Contact Name PER03 Communication Number Qualifier PER04 Communication Number billing_provider_state billing_provider_zip Protocol, Program, Service, Clinic or Institution Protocol, Program, Service, Clinic or Institution billing_provider_addtl_id_qualifier Coverage Plan HIPAA associated with Electronic Claims Type billing_provider_addtl_id Coverage Plan Provider State RV Based on the CSPP level or Institution where the Tax Id is located, select the Billing Address (BI global ). If there is not a Billing Address for the Institution, then Institution Address Zip RV Based on the CSPP level or Institution where the Tax Id is located, select the Billing Address (BI global ). If there is not a Billing Address for the Institution, then Institution Address For coverage plan, look up the electronic claims type. The HIPAA associated with this type will print to the output file. billing_provider_contact_name Used only if address comes from CSPP vs. from the Institution. The value 'Billing Provider Name' will be printed. billing_provider_comm_no_1_qualifier The telephone # based on the CSPP level or Institution where the Tax Id is located. If telephone.type = 'BI' (billing) or 'OP' (office) then 'TE'. If telephone.type = 'BF' (fax) then 'FX'. billing_provider_comm_no_1 Protocol, Program, Service, Clinic or Institution Telephone Will first look for Billing phone #, then Office, then Fax, dependent on the level where the Tax Id is stored. TE = Telephone FX = Facsimile

7 Description Column Name definitions of Global to HIPAA? s to a HIPAA PER05 Communication Number Qualifier PER06 Communication Number billing_provider_comm_no_2_qualifier The telephone # based on the CSPP level or Institution where the Tax Id is located. If telephone.type = 'BI' (billing) or 'OP' (office) then 'TE'. If telephone.type = 'BF' (fax) then 'FX'. billing_provider_comm_no_2 Protocol, Program, Service, Clinic or Institution Telephone Will first look for Billing phone #, then Office, then Fax, dependent on the level where the Tax Id is stored. TE = Telephone FX = Facsimile PER07 Communication Number Qualifier PER08 Communication Number billing_provider_comm_no_3_qualifier The telephone # based on the CSPP level or Institution where the Tax Id is located. If telephone.type = 'BI' (billing) or 'OP' (office) then 'TE'. If telephone.type = 'BF' (fax) then 'FX'. billing_provider_comm_no_3 Protocol, Program, Service, Clinic or Institution Telephone Will first look for Billing phone #, then Office, then Fax, dependent on the level where the Tax Id is stored. TE = Telephone FX = Facsimile Loop 2010AB Pay to Provider will not be included in the 837 file Loop 2000B - Subscriber Hierarchical The Subscriber loop 2000B will repeat each time there is a new insured id and each time within the insured id the provider id changes HL04 Hierarchical Child hier_child_ R If insured is the patient, then '0' else '1' SBR01 Payer Responsibility Sequence Number copay_priority Coverage Copay Priority RV If copay priority = 1, then P; If copay priority = 2, then S; If copay priority >= 3, then T P = Primary S = Secondary T = Tertiary

8 Description Column Name Global to HIPAA? definitions of s to a HIPAA SBR02 Relationship relation_ If insured is the patient, then '18' else leave blank SBR03 Insured Group or Policy Number coverage_group_no Coverage s Insured's Group or Policy Number SBR04 Insured Group Name coverage_plan_name Coverage s Coverage Plan Name SBR05 Insurance Type SBR09 Claim Filing Indicator If the group number on the coverage is blank, the policy number will be sent in the file. If both are blank then nothing is sent in this field. If Group not sent in SBR03, this element is not sent. medicare_type_ t used. Yes claim_filing_ind Global Sub for Payor Type HIPAA User must enter each coverage plan under the Global Sub's payor type, and map the coverage plan to the appropriate HIPAA. If there is no HIPAA mapped to the coverage plan, user will receive a validation error when generating the file. 18 = Self Yes Loop 2000BA - Subscriber Name NM102 Entity Type Qualifier subscriber_entity_qualifier R Always '1' 1 = n-person Entity NM103 Subscriber Last Name subscriber_lname Patient or Relationship Last Name RV If patient is the insured, then patient last name; otherwise last name of the insured relationship NM104 Subscriber First Name suscriber_fname Patient or Relationship First Name If patient is the insured, then patient first name; otherwise first name of the insured relationship NM105 Subscriber Middle Name subscriber_mname Patient or Relationship Middle Name If patient is the insured, then patient middle name; otherwise middle name of the insured relationship

9 Description Column Name Global to HIPAA? definitions of s to a HIPAA NM107 Subscriber Name Suffix subscriber_suffix Patient or Relationship Suffix If patient is the insured, then patient suffix; otherwise suffix of the insured relationship NM108 Identification Qualifier NM109 Subscriber Primary Identifier N301 Subscriber Address Line 1 subscriber_id_qualifier Always 'MI' MI = Member Identification Number subscriber_insured_id Coverage s Insured's Number subscriber_addr_1 Patient or Relationship Address 1 If patient is the insured, then patient address; otherwise address of the insured relationship N302 Subscriber Address Line 2 subscriber_addr_2 Patient or Relationship Address 2 If patient is the insured, then patient address; otherwise address of the insured relationship N401 Subscriber City Name subscriber_city Patient or Relationship City If patient is the insured, then patient city; otherwise city of the insured relationship N402 Subscriber State subscriber_state Patient or Relationship State If patient is the insured, then patient state; otherwise state of the insured relationship N403 Subscriber Postal Zone or ZIP subscriber_zip Patient or Relationship Zip If patient is the insured, then patient zip; otherwise zip of the insured relationship DMG02 Subscriber Birth Date subscriber_dob Patient or Relationship Birthdate If patient is the insured, then patient date of birth; otherwise date of birth of the insured relationship DMG03 Subscriber Gender subscriber_sex Patient or Relationship Sex If patient is the insured, then look up the HIPAA associated with the patient sex; otherwise sex of the insured relationship. Default to U if information not available. U = Unknown Yes Loop 2010BC - Payer Name NM103 Payer Name payor_name Coverage s Coverage Plan Name RV The first 35 characters of coverage plan name

10 Description Column Name Global to HIPAA? definitions of s to a HIPAA NM108 Identification Qualifier payor_id_qualifier R Always 'PI' PI = Payor Identification NM109 Payer Identifier elec_claims_payor_id Coverage Plan, Protocol Payor Information, Program Payor Information, Service Payor Information, Clinic Payor Information window Elec Payor EMC Provider, Provider RV First look to the EMC Provider for the applicable coverage. If not found, based on the CSPP level where the Tax Id is located, look to the Payor Information window for that level for the specific coverage plan, or an ALL row (coverage plan of 'Standard'). If not found, look in the Coverage Plan window for the Provider. Flag as an error if not found N301 Payer Address Line N302 Payer Address Line 2 payor_addr1 Coverage Plan Corporate Address 1 payor_addr2 Coverage Plan Corporate Address N401 Payer City Name payor_city Coverage Plan Corporate Address City N402 Payer State payor_state Coverage Plan Corporate Address State N403 Payer Postal Zone or ZIP payor_zip Coverage Plan Corporate Address Zip If Claim Address is blank, Corporate Address will be pulled into file. If Claim Address is blank, Corporate Address will be pulled into file. If Claim Address is blank, Corporate Address will be pulled into file. If Claim Address is blank, Corporate Address will be pulled into file. If Claim Address is blank, Corporate Address will be pulled into file N404 Payer Country payor_country_ t used in Loop 2010BD - Responsible Party Name NM102 Entity Type Qualifier responsible_qualifier Always '1' 1 = Person NM103 Responsible Party Last or Organization Name responsible_lname Relation Last Name If patient is not financially responsible, the relationship who is marked as financially responsible for the patient.

11 Description Column Name definitions of Global to HIPAA? s to a HIPAA NM104 Responsible Party First Name NM105 Responsible Party Middle Name responsible_fname Relation First Name If patient is not financially responsible, the relationship who is marked as financially responsible for the patient. responsible_mname Relation Middle Name If patient is not financially responsible, the relationship who is marked as financially responsible for the patient NM106 Name Prefix t used NM107 Responsible Party Suffix Name responsible_suffix Relation Suffix If patient is not financially responsible, the relationship who is marked as financially responsible for the patient N301 Responsible Party Address Line N302 Responsible Party Address Line N401 Responsible Party City Name N402 Responsible Party State N403 Responsible Party Postal Zone or ZIP N404 Responsible Party Country Loop 2000C - Patient Hierarchical Level responsible_addr_1 Relation Address 1 If patient is not financially responsible, the relationship who is marked as financially responsible for the patient. responsible_addr_2 Relation Address 2 If patient is not financially responsible, the relationship who is marked as financially responsible for the patient. responsible_city Relation City If patient is not financially responsible, the relationship who is marked as financially responsible for the patient. responsible_state Relation State If patient is not financially responsible, the relationship who is marked as financially responsible for the patient. responsible_zip Relation Zip If patient is not financially responsible, the relationship who is marked as financially responsible for the patient. respsonsible_country_ t used in

12 Description Column Name Global to HIPAA? definitions of s to a HIPAA PAT01 Patient Relationship to Insured patient_relationship Relation Relation (Relation Type global ) If patient is not the insured and the Relation G8 = Other Relationship Type is mapped to a HIPAA, the HIPAA is used. If Relation Type is not mapped to a HIPAA, then 'G8' Yes PAT09 Patient Pregnancy Indicator patient_pregnancy_ind t used in the standard. In most cases, this field is not being kept up to date so we are not using in the standard implementation. Loop 2010CA - Patient Name NM103 Patient Last Name patient_lname Patient Last Name If patient is not the insured, then patient last name NM104 Patient First Name patient_fname Patient First Name If patient is not the insured, then patient first name NM105 Patient Middle Name patient_mname Patient Middle Name If patient is not the insured, then patient middle name NM107 Patient Name Suffix patient_suffix Patient Suffix If patient is not the insured, then patient suffix N301 Patient Address Line N302 Patient Address Line 2 patient_addr_1 Patient Address 1 If patient is not the insured, then patient address 1 patient_addr_2 Patient Address 2 If patient is not the insured, then patient address N401 Patient City Name patient_city Patient City If patient is not the insured, then patient City N402 Patient State patient_state Patient State If patient is not the insured, then patient State N403 Patient Postal Zone or ZIP N404 Patient Country patient_zip Patient Zip If patient is not the insured, then patient Zip patient_country_ t used in

13 Description Column Name definitions of Global to HIPAA? s to a HIPAA DMG02 Patient Birth Date patient_dob Patient Date of Birth If patient is not the insured, then patient date of birth DMG03 Patient Gender Loop Claim Information CLM01 Patient Control Number CLM02 Total Claim Charge patient_sex Patient Sex If patient is not the insured, then look up the HIPAA associated with the sex of the patient. Default to U if information not available. patient_control_no Patient, Claims Submission Patient + Claim total_amt Fee Matrix Charge, Disallowance, Max Print CLM05-1 Facility Type bill_type Coverage Plan POS Coverage Plan Place of Service R RV Patient + Claim (from claims_transaction table) Sum of one of the following for all transactions included in file: If Print Amt Type = 'Net' then Charge less Disallowance. If Print Amt Type = Charges, then Charge. Total Claim Charge will not exceed Max Print Match the Place of Service (POS) from the clinical transaction to the Coverage Plan Place of Service. The value from the Coverage Plan POS will print in the file. If there is no match, the Coverage Plan POS that is indicated to be the Claim Form Default value will print in the file. U = Unknown Yes

14 Description Column Name Global to HIPAA? definitions of s to a HIPAA CLM05-3 Frequency frequency_ Patient Assignment Status RV If patient assignment status is Discharge or Transferred (Inpatient) and the current claim 1 = Admit through Discharge claim 2 = is the first claim being sent then '1'. If patient Interim First Claim 3 = assignment status is Enrolled or On Leave and the current claim is the first claim being Interim Continuing Claim 4 = Last Claim sent then '2'. If patient assignment status is Discharge or Transferred (Inpatient) and the current claim is not the first claim sent then '4'. If patient assignment status is Enrolled or On Leave and the current claim is not the first claim sent, then '3' CLM06 Provider or Supplier Signature Indicator signature_ind RV Always 'Y' Y = Yes CLM07 Medicare Assignment CLM08 Benefits Assignment Certification Indicator medicare_assign_ Coverage s Accept Assignment If Accept Assignment = 'Y' then 'A'. If Accept Assignment = 'N', then 'C'. A = Assigned C = t Assigned benefits_assign_cert_ind Coverage s Accept Assignment RV If Accept Assignment = 'Y' in the Coverage s window, then 'Y'. Otherwise 'N' Y = Yes N = CLM09 Release of Information CLM18 Yes/ Condition or Response release_ RV Always 'Y'. Y = Yes, Provider has a signed statement permitting release of medical billing data related to a claim EOB_indicator RV Always 'N'. N =

15 Description Column Name Global to HIPAA? definitions of s to a HIPAA DTP01 Discharge Hour Qualifier Patient Assignment Discharged Date This is only sent for Inpatient Assignments that have been discharged, and where the frequency sent above (CLM03-5) is either a 1 or a 3. If this is the case, this value is always '096'. 096 = Discharge DTP02 Discharge Hour Patient Assignment DTP03 Discharge Hour discharge_hour Patient Assignment DTP02 Date Time Period Format Qualifier statement_date_qualifier Clinical Transaction Discharged Date If DTP01 is sent, then 'TM' TM = Time Expressed in Format HHMM Discharged Discharge time Date/Time Procedure Date RV Either D8 or RD8, depending upon whether claim covers a single or a range of dates TM = Time Expressed in Format HHMM D8 = Single date RD8 = Range of dates DTP03 Statement From or To Date statement_date Clinical Transaction Procedure Date RV Procedure date on the transaction, with 2 exceptions: (1) If the billing cycle is set for Monthly and the first day of the month precedes the Enrolled date of the Assignment, then Enrolled date for the CSPP on the transaction. (2) If the billing cycle is set for Weekly and the first calendar day of the week precedes the Enrolled date of the Assignment, then Enrolled date for the CSPP on the transaction DTP03 Admission Date and Hour admission_date Patient Assignment Enrolled Date Only sent for Inpatient Assignments.

16 Description Column Name definitions of Global to HIPAA? s to a HIPAA CL101 Admission Type admission_type_ Inpatient ADT Type (Global of Inpatient Status Type) Only sent for Inpatient Assignments. The HIPAA column will be used. If this column is blank, the column from the global window will be used. s are listed in UB 92 Instructions for field 19. Yes CL102 Admission Source admission_source_ Intake (Patient Adm tab) CL103 Patient Status patient_status_ Inpatient ADT Discharge Summary tab or Patient Assignment Referral Source (Global of Referral Source) Discharged To or Patient Assignment Status (Global of Assignment Status or Discharge Location) Only sent for Inpatient Assignments. The HIPAA column will be used. If this column is blank, the column will be used. s are listed in UB 92 Instructions. Only sent for Inpatient Assignments. If there is no discharge date, then Patient Assignment HIPAA is sent. If there is a discharge date, then Discharge Location global is sent. If no Discharge Location, then 30 is sent. 30 = Still a patient or expected to return for outpatient services Yes

17 Description Column Name definitions of Global to HIPAA? s to a HIPAA AMT02 Estimated Claim Due est_claim_due_amt Fee Matrix Charge, Disallowance, Max Print Estimated Due = Owed less Payor Payment For all transactions involved in this claim: Owed is calculated as follows from fee matrix: If Print Amt Type = 'Net', then Charge less Disallowance. If Print Amt Type = Charges, then Charge. owed will not exceed Max Print Payor payment is calculated as follows: The sum of all billing ledgers with a subtype of 'PA' or 'RF'. If the configuration setting of billpaidamtall = 'True' then this sum includes payments by all payors (including the patient). If the configuration setting of billpaidamtall = 'False' then only insurance payors with a coverage priority equal to or less than the current payor are included. Patient payments are excluded AMT02 Patient Responsibility patient_resp_amt Patient Accounts Billing Ledgers From the billing ledger where coverage is Standard AMT02 Patient Paid patient_amt_paid Payment Payment If a patient has made a payment for any services on this claim, this segment will be sent REF01 Reference Identification Qualifier prior_authorization_qualifier If clinical transaction references an authorization, then G1; otherwise leave blank G1 = Prior Authorization Number

18 Description Column Name Global to HIPAA? definitions of s to a HIPAA REF02 Prior Authorization or Referral Number REF02 Medical Record Number 204 K301 Fixed Format Information 228 H101-1 List Qualifier H101-2 Principal diagnosis prior_authorization_no Procedure Authorization (for patient) Auth. medical_record_no Patient MRN emergency_claim_info Diagnosis Document POA Indicates whether or not an Axis III diagnosis is Present on Admission (POA). Requires that Institution or CSPP where patient is Y = Condition was Present on Admission N = Condition was not admitted be designated as a PPS Acute Care Present on Admission facility in PPS Administration configuration Z = End of element settings. principal_diagnosis_qualifier Always 'BK' BK = Principal Diagnosis principal_diagnosis_ Clinical Transaction Axis I & II (Billing Dx) RV This is the Principal diagnosis. The diagnosis in the first position on the clinical transaction with the latest procedure date is assumed to be Principal. The DSMIV diagnoses will be converted to ICD s in the 837 output file H102-1 List Qualifier H102-2 Admitting diagnosis admitting_diagnosis_ Clinical Transaction 233 H101-1 Other diagnosis H101-2 Other diagnosis H102-1 Other diagnosis Qualifier admitting_diagnosis_qualifier Always 'ZZ' ZZ = Mutually Defined other_diagnosis_1_ other_diagnosis_1_ Clinical Transaction Clinical Transaction Axis I & II (Billing Dx) Axis I & II (Billing Dx) Same as the Principal_diagnosis_. Always 'BF', if other diagnosis exist All dx s listed in the clinical transactions included in this claim, other than the Principal dx included in H101. BF = Diagnosis other_diagnosis_2_qualifier Always 'BF', if other diagnosis exist BF = Diagnosis

19 Description Column Name Global to HIPAA? definitions of s to a HIPAA H102-2 Other diagnosis H103-1 Other diagnosis Qualifier H103-2 Other diagnosis H104-1 Other diagnosis Qualifier H104-2 Other diagnosis H105-1 Other diagnosis Qualifier H105-2 Other diagnosis H106-1 Other diagnosis Qualifier H106-2 Other diagnosis 242 HI01-1 List Qualifier 243 HI01-2 Principal procedure other_diagnosis_2_ Clinical Transaction Axis I & II (Billing Dx) All dx s listed in the clinical transactions included in this claim, other than the Principal dx included in H101. other_diagnosis_3_qualifier Always 'BF', if other diagnosis exist BF = Diagnosis other_diagnosis_3_ Clinical Transaction Axis I & II (Billing Dx) All dx s listed in the clinical transactions included in this claim, other than the Principal dx included in H101. other_diagnosis_4_qualifier Always 'BF', if other diagnosis exist BF = Diagnosis other_diagnosis_4_ Clinical Transaction Axis I & II (Billing Dx) All dx s listed in the clinical transactions included in this claim, other than the Principal dx included in H101. other_diagnosis_5_qualifier Always 'BF', if other diagnosis exist BF = Diagnosis other_diagnosis_5_ Clinical Transaction Axis I & II (Billing Dx) All dx s listed in the clinical transactions included in this claim, other than the Principal dx included in H101. other_diagnosis_6_qualifier Always 'BF', if other diagnosis exist BF = Diagnosis other_diagnosis_6_ procedure_1_qualifier procedure_1_ Clinical Transaction Clinical Transaction Clinical Transaction Axis I & II (Billing Dx) Axis III (Diagnosis Dx) Axis III (Diagnosis Dx) All dx s listed in the clinical transactions included in this claim, other than the Principal dx included in H101. Always BR, for ECTs where Institution or CSPP are designated as PPS. If Institution or CSPP is not designated as PPS, always NULL. Always for ECTs where Institution or CSPP are designated as PPS. If Institution or CSPP is not designated as PPS, always NULL. BR = ICD-9-CM principal procedure = Electroconvulsive Therapy

20 Description Column Name Global to HIPAA? definitions of s to a HIPAA 243 HI01-4 Date Time Period procedure_1_date Clinical Transaction Date of the last ECT therapy in CCYYMMDD format. Loop 2310A - Attending Physician Name NM102 Entity Type Qualifier attending_entity_qualifier Always '1' 1 = Person NM103 Attending Provider Last Name NM104 Attending Provider First Name NM105 Attending Provider Middle Name NM108 Identification Qualifier NM109 Attending Provider Identifier attending_lname Staff Last Name Last name of Attending clinician on the clinical transaction attending_fname Staff First Name First name of Attending clinician on the clinical transaction attending_mname Staff Middle Name Middle name of Attending clinician on the clinical transaction attending_id_qualifier Always '24' 24 = Employer's Identification Number attending_id Protocol, Tax Tax reported in Billing Provider loop Program, Service, (2010AA) NM109 Clinic or Institution PRV01 Provider attending_ If a taxonomy exists for the attending clincian, 'AT' PRV03 Provider Taxonomy attending_taxonomy_ Staff Taxonomy 326 REF01 Attending Secondary Qualifier attending_secondary_qualifier Depending upon what is sent in REF02, either 1B, 1C, 1D, 1G, 1H, G2, or SY AT = Attending 1B = Blue Cross, 1C = Medicare, 1D = Medicaid, 1G = Provider UPIN number, G2 = Provider Commercial Number, SY = Staff Social Security Number

21 Description Column Name Global to HIPAA? definitions of s to a HIPAA 327 REF02 Attending Secondary attending_secondary_id Payor Information for Staff or Staff Provider, UPIN Will first look for Provider. If not found, will look for UPIN. If not found will look to staff social security number. If none of the 3 are found, this element will not be sent Loop 2310C - Other Provider Name te: The Other provider segment is used to report Referring provider information. This information is only sent at the Claim level NM103 Other Provider Last Name NM104 Other Provider First Name NM105 Other Provider Middle Name NM108 Other Provider Identification Qualifier NM109 other_provider Provider Identifier other_provider_lname Staff Last Name other_provider_fname Staff First Name other_provider_mname Staff Middle Name other_provider_id_qualifier = Employer's Identification Number other_provider_id Protocol, Tax Program, Service, Clinic or Institution

22 Description Column Name Global to HIPAA? definitions of s to a HIPAA 340 REF01 Other Provider Secondary Identification Qualifier other_provider_secondary_qualifier Depending upon what is sent in REF02, either 1B, 1C, 1D, 1G, 1H, G2, or SY 1B = Blue Cross, 1C = Medicare, 1D = Medicaid, 1G = Provider UPIN number, G2 = Provider Commercial Number, SY = Staff Social Security Number 341 REF02 Other Provider Secondary Identification other_provider_secondary_id Payor Information for Staff or Staff Provider, UPIN or SSN Loop Other Subscriber Information SBR01 Payor Responsibility Sequence Number payor_sequence_no Coverage Priority (opened from Coverage Profile for a patient) Payment Priority If copay priority = 1, then P; If copay priority = 2, then S; If copay priority >= 3, then T P = Primary S = Secondary T = Tertiary SBR02 Individual Relationship relationship_ Relation HIPAA of Relation (Relation Type global ) If insured is the patient, then '18'. Otherwise, look up the HIPAA associated with the relation type of the insured. 18 = Self Yes SBR03 Insured Group or Policy Number group_no Coverage s Insured's Group Coverage Group Number, if available. Otherwise, Coverage Policy Id SBR04 Insured Group Name group_name Coverage s Coverage Plan Name SBR05 Insurance Type insurance_type_ t used.

23 Description Column Name definitions of Global to HIPAA? s to a HIPAA SBR09 Claim Filing Indicator filing_indicator_ Global Sub for Payor Type HIPAA RV User must enter each coverage plan under the Global Sub's payor type, and map the coverage plan to the appropriate HIPAA. If there is no HIPAA mapped to the coverage plan, user will receive a validation error when generating the file. Yes All adjustments will be reported at the service (clinical transaction) level, therefore CAS segment not sent at claim level CAS01 Claim Adjustment adjustment_group_ t applicable Group CAS02 Adjustment Reason adjustment_reason 1 t applicable CAS03 Adjustment adjustment_amt_1 t applicable CAS04 Adjustment Quantity adjustment_quantity_1 t applicable CAS05 Adjustment Reason adjustment_reason 2 t applicable CAS06 Adjustment adjustment_amt_2 t applicable CAS07 Adjustment Quantity adjustment_quantity_2 t applicable CAS08 Adjustment Reason adjustment_reason 3 t applicable CAS09 Adjustment adjustment_amt_3 t applicable CAS10 Adjustment Quantity adjustment_quantity_3 t applicable CAS11 Adjustment Reason adjustment_reason 4 t applicable

24 Description Column Name Global to HIPAA? definitions of s to a HIPAA CAS12 Adjustment adjustment_amt_4 t applicable CAS13 Adjustment Quantity adjustment_quantity_4 t applicable CAS14 Adjustment Reason adjustment_reason 5 t applicable CAS15 Adjustment adjustment_amt_5 t applicable CAS16 Adjustment Quantity adjustment_quantity_5 t applicable CAS17 Adjustment Reason adjustment_reason 6 t applicable CAS18 Adjustment adjustment_amt_6 t applicable CAS19 Adjustment Quantity adjustment_quantity_6 t applicable AMT02 Payor Paid payor_paid_amt Patient Accounts Billing Ledgers where Subtype = Payments AMT02 Total submitted charges. submitted_charges Fee Matrix Charge, Disallowance, Max Print Sum payments for the coverage plan and HSC for the transactions included in claim. The sum of all amounts from the service lines for this claim. For each transactions involved in this claim: If Print Amt Type = 'Net', then Charge less Disallowance. If Print Amt Type = Charges, then Charge. owed will not exceed Max Print AMT02 Total Medicare Paid medicare_paid_amt Patient Accounts Billing Ledgers where Subtype = Payment or Refund Sum billing ledger payments and refunds for the current claim where the coverage plan payor type maps to the HIPAA of 'CP', 'MP' or 'MB CP = Medicare Conditionally Primary MP = Medicare Primary MB = Medicare Part B

25 Description Column Name definitions of Global to HIPAA? s to a HIPAA AMT02 Denied Charge denied_charge_amt Patient Accounts Billing Ledgers Sum Billing ledger denial amounts for all the billing transactions involved in the current claim DMG02 Other Insured Birth Date DMG03 Other Insured Gender OI03 Benefits Assignment Certification Indicator insured_birth_date insured_sex Patient or Relation Patient or Relation benefits_assignment_cert_ind Coverage s Accept Assignment Date of Birth If relative is the insured, then Relation DOB; if patient is the insured, then patient DOB; Default to '00/00/00' if information not available Sex If relative is the insured, then HIPAA associated with Relation sex; if patient is the insured, then HIPAA associated with patient sex. Default to U if information not available If Accept Assignment = 'Y' in the Coverage s window, then 'Y'. Otherwise 'N' U = Unknown Y = Yes N = Yes OI06 Release of Information info_release_ Coverage s Accept Assignment Always 'Y'. Y = The Provider has a signed statement permitting release of medical billing data related to a claim The following information will only be submitted if it is returned on the 835 remittance MIA01 Covered Days or Visits Count mia_covered_days N/A N/A From the 835, the covered days for the billing transactions involved in the current claim MIA02 Lifetime Reserve Days Count mia_lifetime_reserve_days_cnt N/A N/A From the 835, the outlier amount for the billing transactions involved in the current claim

26 Description Column Name definitions of Global to HIPAA? s to a HIPAA MIA03 Lifetime Psychiatric Days Count mia_lifetime_psych_days_cnt N/A N/A From the 835, the psychiatric days for the billing transactions involved in the current claim MIA04 Claim DRG mia_drg_amt N/A N/A From the 835, the drg amount for the billing transactions involved in the current claim MIA05 Remark mia_remark_ N/A N/A Null MIA06 Claim Disproportionate Share mia_disproportionate_share_amt N/A N/A From the 835, the disproportionate share amount for the billing transactions involved in the current claim MIA07 Claim MSP Passthrough MIA08 Claim PPS Capital MIA09 PPS-Capital FSP DRG MIA10 PPS-Capital HSP DRG MIA11 PPS-Capital DSH DRG mia_pass_thru_amt N/A N/A From the 835, the pass through amount for the billing transactions involved in the current claim mia_pps_capital_amt N/A N/A From the 835, the capital amount for the billing transactions involved in the current claim mia_capital_fsp_drg_amt N/A N/A From the 835, the FSP DRG amount for the billing transactions involved in the current claim mia_pps_capital_hsp_drg_amt N/A N/A From the 835, the FSP DRG amount for the billing transactions involved in the current claim mia_pps_capital_dsh_drg_amt N/A N/A From the 835, the FSP DRG amount for the billing transactions involved in the current claim MIA12 Old Capital mia_old_capital_amt N/A N/A From the 835, the Old Capital amount for the billing transactions involved in the current claim MIA13 PPS-Capital IME mia_pps_capital_ime_amt N/A N/A From the 835, the PPS-Capital IME amount for the billing transactions involved in the current claim

27 Description Column Name definitions of Global to HIPAA? s to a HIPAA MIA14 PPS-Operating Hospital Specific DRG MIA15 Cost Report Day Count MIA16 PPS-Operating Federal Specific DRG MIA17 Claim PPS Capital Outlier MIA18 Claim Indirect Teaching MIA19 npayable Professional Component mia_pps_operating_hosp_specific_drg_amt N/A N/A From the 835, the PPS-Operating Hospital Specific DRG amount for the billing transactions involved in the current claim mia_cost_rpt_day_cnt N/A N/A From the 835, the Cost Report Day Count for the billing transactions involved in the current claim mia_pps_operating_fed_spec_drg_amt N/A N/A From the 835, the PPS-Operating Federal Specific DRG amount for the billing transactions involved in the current claim mia_pps_capital_outlier_amt N/A N/A From the 835, the Claim PPS Capital Outlier amount for the billing transactions involved in the current claim mia_indirect_teaching_amt N/A N/A From the 835, the Claim Indirect Teaching amount for the billing transactions involved in the current claim mia_nonpayable_prof_component_amt N/A N/A From the 835, the npayable Professional Component amount for the billing transactions involved in the current claim MIA24 PPS-Capital Exception MOA01 Reimbursement Rate MOA02 HCPCS Payable mia_pps_capital_exception_amt N/A N/A From the 835, the PPS-Capital Exception amount for the billing transactions involved in the current claim moa_reimbursement_rate N/A N/A From the 835, the reimbursement rate for the billing transactions involved in the current claim moa_hcpcs_payable_amt N/A N/A From the 835, the Claim HCPCS Payable amount for the billing transactions involved in the current claim MOA03 Remark moa_remark 1 t used in MOA04 Remark moa_remark 2 t used in MOA05 Remark moa_remark 3 t used in.

28 Description Column Name definitions of Global to HIPAA? s to a HIPAA MOA06 Remark moa_remark 4 t used in MOA07 Remark moa_remark 5 t used in MOA09 n-payable Professional Component Billed moa_non_payable_professional_amt N/A N/A From the 835, the npayable Professional Componenet amount for the billing transactions involved in the current claim Loop 2330A - Other Subscriber Name NM102 Entity Type Qualifier insured_qualifier Always '1' 1 = Person NM103 Other Insured Last Name NM104 Other Insured First Name NM105 Other Insured Middle Name NM107 Other Insured Name Suffix NM108 Identification Qualifier NM109 Other Insured Identifier insured_lname insured_fname insured_mname insured_suffix NM3 prints when NM1(2330A) prints and N301 is populated N301 Other Insured Address Line 1 insured_addr_ N302 Other Insured Address Line 2 Patient or Relation Patient or Relation Patient or Relation Last Name If patient is not the insured, then relationship last name. If patient is the insured, then patient last name First Name If patient is not the insured, then relationship first name. If patient is the insured, then patient first name Middle Name If patient is not the insured, then relationship middle name. If patient is the insured, then patient middle name t used. insured_id_qualifier Always 'MI' MI = Member Identification Number insured_id Coverage s Insured insured_addr_2 Patient or Relation Patient or Relation Address 1 Address 2 If patient is not the insured, then relationship address 1. If patient is the insured, then patient address 1. If patient is not the insured, then relationship address 2. If patient is the insured, then patient address 2.

29 Description Column Name Global to HIPAA? definitions of s to a HIPAA N401 Other Insured City Name insured_city Patient or Relation City If patient is not the insured, then relationship city. If patient is the insured, then patient city N402 Other Insured State insured_state Patient or Relation State If patient is not the insured, then relationship state. If patient is the insured, then patient state N403 Other Insured Postal Zone or ZIP insured_zip Patient or Relation Zip If patient is not the insured, then relationship zip. If patient is the insured, then patient zip N404 Subscriber Country insured_country_ t used in. Loop 2330B - Other Payer Name NM103 Other Payor Last or Organization Name payor_name Coverage s Coverage Plan Name The first 35 characters of coverage plan name NM108 Identification Qualifier NM109 Other Payor Primary Identifier payor_qualifier Always 'PI' PI = Payor Identification payor_id Coverage Plan, EMC Provider, Protocol Payor Provider Information, Program Payor Information, Service Payor Information, Clinic Payor Information Look to the EMC Provider for the applicable coverage. If not found, based on the CSPP level where the Tax Id is located, look to the Payor Information window for that level for the specific coverage plan, or an ALL row (coverage plan of 'Standard'). If not found at any level of CSPP, look in the Coverage Plan window for the Provider. Flag as an error if not found N301 Other Payer Address Line N302 Other Payer Address Line payor_addr_1 Coverage Plan Corporate Address 1 payor_addr_2 Coverage Plan Corporate Address 2

30 Description Column Name Global to HIPAA? definitions of s to a HIPAA N401 Payer City Name payor_city Coverage Plan Corporate Address City N402 Payer State payor_state Coverage Plan Corporate Address State N403 Payer Postal Zone or ZIP payor_zip Coverage Plan Corporate Address Zip N404 Payer Country payor_country_ t used in DTP03 Adjudication or Payment Date REF01 Reference Identification Qualifier REF02 Other Payor Prior Authorization or Referral Number Loop 2330B - Other Payer Patient Information NM108 Identification Qualifier NM109 Other Payor Patient Primary Identifier payment_date payor_authorization_qualifier payor_authorization_no Procedure Authorization (for patient) Auth. t used. This will be populated on the service line in loop If clinical transaction references an authorization, then G1; otherwise leave blank G1 = Prior Authorization Number patient_id_qualifier Always 'MI' MI = Member Identification Number patient_id Coverage s Insured REF01 Reference Identification Qualifier REF02 Other Payor Secondary Identifier patient_secondary_qualifier patient_secondary_id t Used in t Used in Loop 2330E - Other Payer Attending Name NM102 Entity Type Qualifier attending_provider t used in.

31 Description Column Name definitions of Global to HIPAA? s to a HIPAA REF01 Reference Identification Qualifier REF02 Other Payor Secondary Identifier attending_id_qualifier attending_id t used in t used in Loop Service Line Number SV201 Revenue revenue_ Revenue Revenue R Similar w/existing functionality, Revenue will be generated at time claim is generated SV202-1 Product or Service Qualifier service_id_qualifier Always 'HC' HC = Health Care Financing Administration Common Procedural Coding System (HCPCS) s SV202-2 Procedure proc_ CPT s CPT Similar w/existing functionality, CPT will be generated at time claim is generated SV202-3 HCPCS Modifier 1 HCPCS_modifier_1 CPT s Mod I Modifier associated with CPT found in SV SV202-4 HCPCS Modifier 2 HCPCS_modifier_2 CPT s Mod II Modifier associated with CPT found in SV SV202-5 HCPCS Modifier 3 HCPCS_modifier_3 CPT s Mod III Modifier associated with CPT found in SV SV202-6 HCPCS Modifier 4 HCPCS_modifier_4 t used in

32 Description Column Name definitions of Global to HIPAA? s to a HIPAA SV203 Line Item Charge line_item_charge_amt Fee Matrix Charge, Disallowance, Max Print R Sum of one of the following: If Print Amt Type = 'Net' then Charge less Disallowance. If Print Amt Type = Charges, then Charge. Total Charge will not exceed Max Print SV204 Unit or Basis for Measurement unit_of_measure R Always 'UN' UN = Unit SV205 Service Unit Count service_unit_count Clinical Transaction Matrix Fee Procedure Duration Print Unit R If Procedure Duration divided by Print Unit is greater than the Max Print Unit in Fee Matrix, then Max Print Unit. Otherwise, Procedure Duration / Print Unit. (Similar to HCFA 1500 Box 24G) SV206 Service Line Rate service_line_rate If HSC = 'OP' then CPT. If HSC = 'IP', then charge amt divided by service unit count. This element must be sent when revenue_ = ' ' SV207 Line Item Denied Charge or n- Covered Charge denied_charge_amt t used in DTP02 Date Time Period Format Qualifier service_date_qualifier Clinical Transaction Procedure Date Always 'D8' D8 = Date expressed in format CCYYMMDD

33 Description Column Name definitions of Global to HIPAA? s to a HIPAA DTP03 Service Date service_date Clinical Transaction Procedure Date Only sent if claim is not for an inpatient visit. Procedure date on the transaction, with 2 exceptions: (1) If the billing cycle is set for Monthly and the first day of the month precedes the Enrolled date of the Assignment, then Enrolled date for the CSPP on the transaction. (2) If the billing cycle is set for Weekly and the first calendar day of the week precedes the Enrolled date of the Assignment, then Enrolled date for the CSPP on the transaction. te: The Other provider segment is used to report Referring provider information. This information is only sent at the Claim level, and is no longer sent at the Service Level. Loop Service Line Adjudication Information This loop is used when the claim has been previously adjudicated and there were adjustments If an 835 was received and amounts were adjusted, they will be included in this CAS adjustment segment. If payment information was manually entered, it will also be included in this adjustment segment if a Denial has been associated with the billing ledger.

34 Description Column Name Global to HIPAA? definitions of s to a HIPAA SVD01 Other Payer Primary Identifier other_payor_primary_id Protocol Payor Provider Information, Program Payor Information, Service Payor Information, Clinic Payor Information or Coverage Plan window Based on the CSPP level where the Tax Id is located, look to the Payor Information window for that level. If not found, look in the Coverage Plan window for the Provider. Flag as an error if not found SVD02 Service Line Paid SVD SVD SVD SVD SVD SVD SVD03-7 Product or Service Qualifier other_paid_amt Patient Accounts Billing Ledgers where Subtype = Payment or Refund Sum payments for this particular coverage plan and HSC for transactions included in claim. other_svc_id_qual Always 'HC' HC = Health Care Financing Administration Common Procedural Coding System (HCPCS) s Procedure other_proc_cd CPT returned on the 835 remittance. Procedure Modifier 1 other_modifier_1 Procedure Modifier 2 other_modifier_2 Procedure Modifier 3 other_modifier_3 Procedure Modifier 4 other_modifier_4 Procedure Description other_proc_desc returned on the 835 remittance. returned on the 835 remittance. returned on the 835 remittance. t used. returned on the 835 remittance.