HEALTH CARE CLAIM: PROFESSIONAL 837 (004010X098A1)

Transcription

1 HALTH CAR CLAIM: PROFSSIONAL 837 (0040X8A1) Use this Companion ocument when creating UnitedHealthcare professional claim transactions. ach state may have a list of required and conditionally required clean claim data elements, consistent with this companion document and applicable state laws, including but not limited to state prompt pay laws. Those state law required and conditionally required clean claim data elements may be found in state laws and regulations, contracts and Administrative Guides, and are incpated into this companion document by reference. Note: National Provider Identifiers (NPI s) will be issued beginning in May This Companion ocument has been updated to reflect the implementation requirements f NPI s. We will continue to process the HIPAA standard transactions regardless of whether not NPI is present if it has enough infmation f us to process. This means we will not reject a transaction on the basis of missing increct NPI unless we cannot process the transaction without this infmation. We are considering a timeframe in which we will reject transactions that come in without NPI. Analysis of this timeframe will partially be based on how the overall industry implementation goes May 23rd, 2007 and after. Any changes to our current policy f accepting transactions without NPI will be preceded with communications to physicians, health care professionals, ganizations and trading partners regarding the timeframe in which we expect to begin to reject HIPAA transactions that do not contain an NPI in the fields specified by the Implementation Guide.

2 Special Note Regarding elimiters: UnitedHealthcare sends the following delimiters in 835 Health Care Claim Payment/Advice transactions. Please do not transmit these characters in any data field in the 837 Health Care Claim transaction. CHARACTR NAM LIMITR ISA Comment * Asterisk ata lement Separat Byte 4 ^ Caret Repetition Separat Byte 83 sent in X12 version and higher : Colon Component lement Separat Byte 5 ~ Tilde Segment Terminat Byte 6 ~ doc 2 Printed 8/23/2007

3 NOT: This companion document has been updated to reflect proper 837 claim submissions with NPI number(s). F claim submissions without NPI(s), please submit the TIN / IN in the NM1 data element. LOOP 2000 A BILLING/PAY-TO PROVIR HIRARCHICAL LVL 76 PRV S Billing/pay-to specialty infmation LOOP 20 AA BILLING PROVIR NAM 82 NM2 65 M I 1/1 R ntity Type Qualifier X12 1 = Person 2 = Non- Person When rendering submitted in loop 2000A, submit rendering specialty infmation in this segment ntity type 1 = person entity - physicians and other healthcare professionals 82 NM NM NM NM O AN 1/35 R Billing Provider Last Name Organization Name O AN 1/25 S Billing Provider First Name O AN 1/25 S Billing Provider Middle Name Initial O AN 1/ S Billing Provider Name Suffix ntity type 2 = non-person entity - ganizations F entity type 1 (person) submit the billing last name F entity type 2 (non-person) submit the billing ganization name Only applies to entity type 1 (person) submit the billing first name Only applies to entity type 1 (person) submit the billing middle name middle initial Only applies to entity type 1 (person) submit the billing name suffix ~ doc 3 Printed 8/23/2007

4 83 NM1 67 X AN 2/80 R Billing X12 88 RF S Billing identification Provider SSN (required). ~ doc 4 Printed 8/23/2007

5 LOOP 20 AB PAY-TO PROVIR NAM 82 NM2 65 M I 1/1 R ntity Type Qualifier X12 1 = Person 2 = Non- Person ntity type 1 = person entity - physicians and other healthcare professionals 82 NM NM NM NM NM O AN 1/35 R Pay-To Provider Last Name Organization Name O AN 1/25 S Pay-To Provider First Name O AN 1/25 S Pay-To Provider Middle Name Initial O AN 1/ S Pay-To Provider Name Suffix 67 X AN 2/80 S Pay-to ntity type 2 = non-person entity - ganizations F entity type 1 (person) submit the pay-to last name F entity type 2 (non-person) submit the pay-to ganization name Only applies to entity type 1 (person) submit the pay-to first name Only applies to entity type 1 (person) submit the pay-to middle name middle initial Only applies to entity type 1 (person) submit the pay-to name suffix ~ doc 5 Printed 8/23/2007

6 1 RF S Pay-to- identification X12 The following instructions apply only when there is a Pay-to Provider loop: Provider SSN LOOP 2300 CLAIM INFORMATION 170 TP S ate initial treatment Submit Initial Treatment ate f SR services 193 TP S ate admission 258 HCP S Claim pricing/ repricing infmation Submit Initial Treatment ate f dental services required as the result of an accident Submit Admission ate f R visits when patient is admitted from the R Submit pricing infmation f priced claims in the HCP segment of Loop 2400 (line level) ~ doc 6 Printed 8/23/2007

7 LOOP 23A RFRRING PROVIR NAM 271 NM1 67 X AN 2/80 S Referring X RF S Referring identification LOOP 23B RNRING PROVIR NAM 278 NM1 67 X AN 2/80 R Rendering 279 PRV 2/3 S Provider Taxonomy code 281 RF S Rendering Provider identification LOOP 23C PURCHAS SRVIC PROVIR NAM 285 NM1 67 X AN 2/80 S Purchased service Provider SSN Provide the taxonomy code when available in field PRV03. Provider SSN 286 RF S Purchased service identification Provider SSN ~ doc 7 Printed 8/23/2007

8 LOOP 23 SRVIC FACILITY LOCATION 290 NM1 67 X AN 2/80 S Service Facility Location 294 RF S Service Facility Location identification LOOP 23 SUPRVISING PROVIR NAM 298 NM1 67 X AN 2/80 S Supervising Provider SSN. Use qualifier TJ 299 RF S Supervising Provider identification Provider SSN. ~ doc 8 Printed 8/23/2007

9 es ign at LOOP 2320 OTHR SUBSCRIBR INFORMATION 302 SBR M I 1/1 R Pay responsibility sequence number 302 SBR02 69 O I 2/2 R Individual relationship code 303 SBR O AN 1/30 S Group policy number 304 SBR O I 1/3 R Insurance type code 315 AMT AMT MG MG M R 1/18 R Pay paid amount 782 M R 1/18 R Allowed amount 1251 X AN 1/35 R Other insured birth date 68 O I 1/1 R Other insured gender X12 Submit an other payer responsibility sequence number on COB claims when UHC is to other commercial Submit an other subscriber relationship code on COB claims when UHC is to other commercial Submit an other subscriber policy number on COB claims when UHC is to other commercial Submit an other payer type code on COB claims when UHC is to Medicare other commercial Submit an other payer claim level paid amount on COB claims when UHC is to Medicare other commercial Submit an other payer claim level allowed amount on COB claims when UHC is to other commercial Submit an other subscriber birth date on COB claims when UHC is to other commercial Submit an other subscriber gender code on COB claims when UHC is to other commercial ~ doc 9 Printed 8/23/2007

10 es ign at LOOP 2320 OTHR SUBSCRIBR INFORMATION 329 OI03 73 O I 1/1 R Assignment of Benefits indicat 329 OI O I 1/1 S Patient siure source 329 OI O I 1/1 R Release of infmation LOOP 2330A OTHR SUBSCRIBR NAM 335 NM 3 35 O AN 1/35 R Other insured last name 335 NM NM NM 9 36 O AN 1/25 S Other insured first name 37 O AN 1/25 S Other insured middle initial 67 X AN 2/80 R Other Insured Primary I X12 Submit an other assignment of benefits on COB claims when UHC is to other commercial Submit an other patient siure source on COB claims when UHC is to other commercial Submit an other release of infmation on COB claims when UHC is to other commercial Submit an other subscriber last name on COB claims when UHC is to other commercial Submit an other subscriber first name on COB claims when UHC is to other commercial Submit an other subscriber middle initial on COB claims when UHC is to other commercial Submit an other subscriber I on COB claims when UHC is to other commercial ~ doc Printed 8/23/2007

11 es ign at LOOP 2330B OTHR PAYOR NAM 343 NM NM 9 35 O AN 1/35 R Other pay name 67 X AN 2/80 R Other pay Primary I 349 TP M AN 1/35 R Other payer adjudication date X12 Submit the other pay name on COB claims when UHC is to other commercial Submit the other pay I on COB claims when UHC is to other commercial Submit the other pay adjudication dateon COB claims date when UHC is to other commercial es ign at LOOP 2400 SRVIC LIN 385 SV3 355 X I 2/2 R Unit Basis f Measurement X12 MJ Minutes Submit code MJ when repting anesthesia minutes in Loop 2400 SV4 385 SV4 380 X R 1/15 R Quantity Units Submit a maximum unit quantity of 999 per occurrence of Loop 2400 SV1. When unit quantity is greater than 999, submit multiple occurrences with up to 999 units per occurrence. Minutes Submit quantity as minutes f time based anesthesia services, using MJ qualifier in Loop 2400 SV3 ~ doc 11 Printed 8/23/2007

12 es ign at 440 MA O I 2/2 S Measurement Identification code X12 Hematocrit (HCT) test level is requested on all claims with services f erythropoietin (PO). Submit reference identification code= TR. 440 MA O I 1/3 S Hematocrit Qualifier 440 MA X R 1/20 S Hematocrit test results 461 AMT S Sales tax amount 462 AMT0 782 M R 1/18 R Approved 2 Amount 466 PS1 S Purchased Service Infmation 472 HCP S Line pricing/ repricing infmation Submit qualifier R2 to indicate test results being repted is f Hematocrit Submit Hematocrit test result value. Submit Sales Tax Amount when sales tax applies to the service rendered Submit a line level Medicare approved amount on COB claims when UHC is to Medicare Submit Purchased Service Infmation when contract between UHG and the indicates reimbursement based on a percentage of invoice Submit Line Pricing Infmation f priced claims. LOOP 24 RUG INTIFICATION 478 LIN S rug Identification X12 Submit NC f all unlisted injectable drugs and f other injectable drugs when required per the contract between UHG and the ~ doc 12 Printed 8/23/2007

13 LOOP 2420A RNRING PROVIR NAM 488 NM1 67 X AN 280 R Rendering X PRV S Rendering Provider Specialty Infmation 491 RF Rendering LOOP 2420B PURCHAS SRVIC PROVIR NAM 495 NM1 67 X AN 280 S Purchased service When rendering submitted in loop 2420A, submit rendering specialty infmation in this segment Provider SSN. 496 RF Purchased service LOOP 2420C SRVIC FACILITY LOCATION 500 NM1 67 X AN 280 S Servicing facility primary Provider SSN. 504 RF Servicing facility LOOP 2420 SUPRVISING PROVIR NAM Submit Tax identification number, qualifier TJ ~ doc 13 Printed 8/23/2007

14 508 NM1 67 X AN 280 S Supervising X12 5 RF Supervising LOOP 2420 ORRING PROVIR NAM 513 NM1 67 X AN 280 S Ordering Provider SSN. 518 RF Ordering Provider SSN. es ign at LOOP 2420F RFRRING PROVIR NAM 524 NM 9 67 X AN 280 S Referring service X RF Referring service LOOP 2430 LIN AJUICATION INFORMATION Provider SSN. ~ doc 14 Printed 8/23/2007

15 es ign at 534 SV M R 1/18 S Service Line Paid Amount 539 CAS01 33 M I 1/ 2 S Claim adjustment group code 539 CAS02 34 M I 1/5 S Claim adjustment reason code 539 CAS M R 1/18 S Adjustment amount X12 Submit a line level primary paid amount on COB claims when UHC is Submit an other payer claim adjustment group code on COB claims when UHC is Submit an other payer claim adjustment reason code on COB claims when UHC is Submit an other payer adjustment amount on COB claims when UHC is ~ doc 15 Printed 8/23/2007