Vendor Specifications 837 Professional Claim ASC X12N Version for. State of Idaho MMIS

Transcription

1 Vendor Specifications 837 Professional Claim ASC X12N Version 5010 for State of Idaho MMIS Date of Publication: 12/8/2017 Document Number: TL427 Version: 11.0

2 Revision History Versio Date Author Action/Summary of Changes n /01/2011 Molina Initial document /05/2012 Alisa Nicolls Updated the SV105 segment in 2400 to an S instead of an R /05/2012 TQD Promoted to next whole version /18/2012 Alisa Nicolls Updated the 2010BA NM109 segment with approved language per 10 digit M /19/2012 TQD Promoted to the next whole version /22/2014 M McFadden Added ICD-10 references 4.0 5/23/2014 TQD Promoted to next whole version. DHW validated 5/ /17/2014 D Greer Added multiple values and element separators that were missing from Figure /24/2014 TQD Promoted to next whole version. DHW validated 9/ /06/2014 M McFadden Updated 2310C NM109 value NPI - do not send if same as for Billing Provider for CCF 10735B1 issue identified post-implementation /20/2014 TQD Finalized and published per notification 30-day response agreement /19/2015 Doug Greer Semi-annual review performed - corrections made 7.0 6/8/2015 TQD DHW validated 6/5/ /8/2015 Doug Greer Changed. from S to R for Health Care Diagnosis 8.0 6/23/2015 TQD DHW validated 6/22/ /15/2015 Cathy Butler Semi-annual changes 9.0 1/25/2016 TQD DHW validated changes 1/22/ /26/2016 Douglas Semi-annual Review Corrections made Greer /16/2016 TQD DHW validated changes 6/10/ /21/2017 Cathy Butler Semi-annual review; no updates necessary /29/2017 Douglas Semi-annual review; no updates nessasary. Greer /24/2017 D Greer Added Ordering and Referring provider loops at the service line level for CR /8/2017 TQD Finalized and published per notification 30-day response agreement. Last Updated: 12/8/2017 Page ii

3 DISCLAIMER The Molina Healthcare Companion Guide for Idaho is subject to change at the instruction of the Department. Therefore, it is the responsibility of the trading partner to ensure that the latest version of this guide is used when designing/ building X12N 5010 EDI transactions. The trading partner should frequently check for updates to the companion guide. Molina Healthcare accepts no liability for any costs that the trading partner may incur that arise from or are related to changes to the companion guide. Last Updated: 6/16/2016 Page iii

4 Table of Contents 1. Companion Guide Purpose uired Information Trading Partner Delimiters Additional Information Professional Claim... 3 Appendix A Table of Figures Figure 2-1: 837 Professional Claim... 3 Last Updated: 12/8/2017 Page iv

5 1. Companion Guide Purpose This companion guide documents the transaction type listed below and further defines situational and required data elements that are used for processing claims for programs administered by Idaho Medicaid. This document is not the complete EDI transaction format specifications. Please refer to the 5010A1 Technical Report Type 3 for information not supplied in this document, such as code lists, definitions, and edits. Health Care Claim: Professional (837P) ASC X12N/005010X222A1 For any questions, or to begin testing, please contact the EDI Helpdesk at 1 (866) , option 2, or Molina at idedisupport@molinahealthcare.com uired Information Data elements, segments, and loops not included in this guide are not used for processing claims by Idaho Medicaid, but must still be sent if the information is required for compliance with the ASC X12N version 5010A1 format Trading Partner A trading partner is defined as any entity with which Molina exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Idaho Medicaid s Health PAS system supports the following categories of trading partner: Provider Billing Agency Clearinghouse Health Plan Molina will assign trading partner s to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. All trading partners must be authorized to submit production EDI transactions. Any trading partner may submit test EDI transactions. Trading partners must have a T in ISA15 in all submitted test files. Authorization is granted on a per transaction basis. For example, a trading partner may be certified to submit 837P professional claims but not certified to submit 837I institutional claim files. Trading partners must submit three test files of a particular transaction type, with a minimum of 15 transactions within each file, and have no failures or rejections in order to become certified for production. Users will be notified via and the Trading Partner Status page of Health PAS-Online when testing for a particular transaction has been completed. Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may be found in Appendix A of this document. To obtain a trading partner please visit the Molina Medicaid website at or contact Molina at 1 (866) , option 2. Last Updated: 12/8/2017 Page 1 of 40

6 1.3. Delimiters Idaho Medicaid does not require the use of specific values for the delimiters used in electronic transactions. The suggested values are included in the specifications below Additional Information Please refer to the 5010 Technical Report Type 3 (TR3) for information not supplied in this document, such as code lists, definitions, and edits. Last Updated: 12/8/2017 Page 2 of 40

7 Professional Claim Figure 2-1: 837 Professional Claim HEADER ISA Interchange Control Header 3 R ISA ISA01 Authorization Information 2 I01 R 00 ISA02 Authorization Information AN 10 I02 R Space fill ISA03 Security Information 2 I03 R 00 ISA04 Security Information AN 10 I04 R Space fill ISA05 Interchange 2 I05 R ZZ ISA06 Interchange Sender AN 15 I06 R Molina assigned trading partner + 3 spaces, i.e. TP spaces ISA07 Interchange 2 I05 R ZZ ISA08 Interchange Receiver AN 15 I07 R _MMIS_4MOLINA ISA09 Interchange Date DT 6 I08 R YYMMDD ISA10 Interchange Time TM 4 I09 R HHMM ISA11 Repetition Separator 1 I10 R ^ Last Updated: 12/8/2017 Page 3 of 40

8 ISA12 Interchange Version Number 5 I11 R ISA13 Interchange Control Number N0 9 I12 R Must be identical to the interchange trailer IEA02 (defined by sending Trading Partner) ISA14 Ack. uested 1 I13 R 1 (Interchange acknowledgement requested) ISA15 Usage Indicator 1 I14 R P or T (Must contain a P indicator in production) ISA16 Component Element Separator 1 I15 R : GS Functional Group Header 2 R GS GS01 Functional Identifier R HC GS02 Application Sender's AN 2/ R Molina assigned trading partner GS03 Application Receiver's AN R _MMIS_4MOLINA GS04 Date DT R CCYYMMDD GS05 Time TM 4/8 337 R HHMM GS06 Group Control Number N0 1/9 28 R Assigned by Sender GS07 Responsible Agency 1/2 455 R X Last Updated: 12/8/2017 Page 4 of 40

9 GS08 Version / Release AN R X222A1 ST Transaction Set Header 2 R ST ST01 Transaction Set Identifier R 837 ST02 Transaction Set Control Number AN 4/9 329 R Sequential number assigned by sender ST and SE must be equivalent ST03 Implementation Convention AN 1/35 O X222A1 Reference BHT Beginning Hierarchical 3 R BHT Transaction BHT01 Hierarchical Structure R 0019 BHT02 Transaction Set Purpose R 00 = Original BHT03 Reference identification AN 1/ R Submitter Transaction Identifier BHT04 Date DT R CCYYMMDD Transaction Set Creation Date BHT05 Time TM 4/8 337 R HHMM Transaction Set Creation Time BHT06 Transaction Type R CH = Chargeable Last Updated: 12/8/2017 Page 5 of 40

10 RP = Reporting (use for encounters) 1000A NM1 Submitter Name 3 R NM1 NM101 Entity Identifier 2/3 98 R 41 NM102 Entity Type R 1 or 2 NM103 Name Last or Organization AN 1/ R Name NM104 Name First AN 1/ S NM105 Name Middle AN S NM106 Name Prefix AN 1/ S NM107 Name Suffix AN 1/ S NM108 Identification 1/2 66 R 46 NM109 Identification AN 2/80 67 R Trading Partner 1000A PER Submitter EDI Contact 3 R PER Information PER01 Contact Function 2/2 366 R IC PER02 Name AN 1/60 93 S PER03 Communication Number 2/2 365 R TE - Telephone Last Updated: 12/8/2017 Page 6 of 40

11 PER04 Communication Number AN 1/ R 1000B NM1 Receiver Name 3 R NM1 NM101 Entity Identifier 2/3 98 R 40 NM102 Entity Type R 2 NM103 Name Last or Organization AN 1/ R _MMIS_4MOLINA Name NM104 Name First AN 1/ N NM105 Name Middle AN N NM106 Name Prefix AN 1/ N NM107 Name Suffix AN 1039 N NM108 Identification 1/2 66 R 46 NM109 Identification AN R _MMIS_4MOLINA 2000A HL Billing/Pay-to Provider 2 R HL Hierarchical Level HL01 Hierarchical Number AN R 1 HL03 Hierarchical Level 1/2 735 R 20 HL04 Hierarchical Child 1/1 736 R 1 Last Updated: 12/8/2017 Page 7 of 40

12 2000A PRV Billing/Pay-to Provider 3 S PRV Specialty Information PRV01 Provider 1/ R BI = Billing PRV02 Reference Identification 2/3 128 R PXC PRV03 Reference Identification AN 1/ R Provider Taxonomy 2010AA NM1 Billing Provider Name 3 R NM1 NM101 Entity Identifier 2/3 98 R 85 NM102 Entity Type 1/ R 1 or 2 NM103 Name Last or Organization AN 1/ R Name NM104 Name First AN 1/ S NM105 Middle Name AN 1/ S NM107 Name Suffix AN 1/ S NM108 Identification 1/2 66 S XX = National Provider (NPI) NM109 Identification AN 2/80 67 S NPI Last Updated: 12/8/2017 Page 8 of 40

13 2010AA N3 Billing Provider Address AN 2 R N3 N301 Address Information AN 1/ R N302 Address Information AN 1/ S uired if a second address line exists. 2010AA N4 Billing Provider City/State/Zip AN 2 19 R N4 N401 City Name AN 2/30 19 R N402 State or Province 2/2 156 R N403 Postal 5/9 116 R 2010AA REF Billing Provider Secondary 3 R REF Identification REF01 Reference Identification 2/3 128 R EI = Employer s Identification Number REF02 Reference Identification AN 1/ R EIN 2000B HL Subscriber Hierarchical Level 2 R HL HL01 Hierarchical Number AN R 2 HL02 Hierarchical Parent Number AN 1/ R HL03 Hierarchical Level 1/2 735 R 22 Last Updated: 12/8/2017 Page 9 of 40

14 HL04 Hierarchical Child 1/1 736 R B SBR Subscriber Information 3 O SBR SBR01 Payer Responsibility Sequence 1/ R P, S, or T Number SBR02 Individual Relationship 2/ S 18 SBR03 Reference Identification AN 1/ S SBR04 Name AN 1/60 93 S SBR05 Insurance Type 1/ S SBR09 Claim Filing Indicator 1/ S MC 2010BA NM1 Subscriber Name 3 R NM1 NM101 Entity Identifier 2/3 98 R IL NM102 Entity Type R 1 NM103 Name Last Organization AN 1/ R NM104 Name First AN 1/ R NM105 Name Middle AN 1/ S Last Updated: 12/8/2017 Page 10 of 40

15 NM107 Name Suffix AN 1/ S NM108 Identification 1/2 66 R MI NM109 Identification AN 7/10 67 R Enter the Idaho Medicaid participant s 10 digit identification number. Always add leading zeroes to make a total of 10 digits if the participant s card reflects 7 digits. 2010BA N3 Subscriber Address AN 2 R N3 N301 Address Information AN 1/ R N302 Address Information AN 1/ S uired if a second address line exists. 2010BA N4 Subscriber City/State/Zip AN 2 19 S N4 N401 City Name AN 2/30 19 R N402 State or Province 2/2 156 R N403 Postal 5/9 116 R 2010BA DMG Subscriber Demographic 3 R DMG Information DMG01 Date Time Period Format 2/ R D8 Last Updated: 12/8/2017 Page 11 of 40

16 DMG02 Date Time Period AN 1/ R CCYYMMDD Date of Birth DMG03 Gender R M = Male F = Female U = Unknown 2010BB NM1 Payer Name 3 R NM1 NM101 Entity Identifier 2/3 98 R PR NM102 Entity Type R 2 NM103 Name Last or Organization AN 1/ R _MMIS_4MOLINA NM108 Identification 1/2 66 R PI = Payer Identification NM109 Identification AN 2/80 67 R _MMIS_4MOLINA REF Billing Provider Secondary 3 S REF Identification REF01 Reference Identification 2/3 M G2 REF02 Reference Identification AN 1/50 M Provider Medicaid (Atypical Providers) 2300 CLM Claim Information 3 R CLM Last Updated: 12/8/2017 Page 12 of 40

17 CLM01 Claim Submitter s Identifier AN 1/ R Patient Account Number CLM02 Monetary Amount R 1/ R Total Claim Charges CLM05 Health Care Service Location C023 R Information CLM05-1 Facility AN 1/ R CLM05-2 Facility 1/2 R B CLM05-3 Claim Frequency Type R CLM06 Yes/No Condition or Response R CLM07 Provider Accept Assignment R CLM08 Yes/No Condition or Response R CLM09 Release of Information R CLM10 Patient Signature Source S P CLM11 Related Causes Information C024 S CLM11-1 Related Causes 2/ R AA = Auto Accident OA = Other Accident EM = Employment CLM11-2 Related Causes 2/ S Last Updated: 12/8/2017 Page 13 of 40

18 CLM11-3 Related Causes 2/ S CLM11-4 State or Province S uired if CLM11-1, CLM11-2, or CLM11-3 = AA to identify the state in which the automobile accident occurred. Use state code. CLM11-5 Country 2/3 26 S uired if the auto accident outside the U.S. to identify the country in which the accident occurred. CLM12 Special Program 2/ S CLM20 Delay Reason 1/ S 2300 DTP Date Onset of Current 3 S DTP Illness/Symptom DTP01 Date/Time R 431 DTP02 Date Time Period Format 2/ R D8 DTP03 Date Time Period AN 1/ R CCYYMMDD Last Updated: 12/8/2017 Page 14 of 40

19 2300 DTP Date Accident 3 S DTP uired if CLM11-1, -2, or - 3 = AA or OA DTP01 Date/Time R 439 DTP02 Date Time Period Format 2/ R D8 DTP03 Date Time Period AN 1/ R CCYYMMDD 2300 AMT Patient Amount Paid 3 S AMT AMT01 Amount 1/3 522 R F5 AMT02 Monetary Amount R 1/ R 2300 REF Prior Authorization or Referral 3 S REF Number REF01 Reference Identification 2/3 128 R 9F = Referral Number REF02 Reference Identification AN 1/ R Assigned Referral Number 2300 REF Prior Authorization or Referral 3 S REF Number REF01 Reference Identification 2/3 128 R G1 = Prior Authorization Number REF02 Reference Identification AN 1/ R Assigned Prior Authorization Number Last Updated: 12/8/2017 Page 15 of 40

20 2300 REF Original Reference Number 3 S REF REF01 Reference Identification 2/3 128 R F8 = Original Reference Number REF02 Reference Identification AN 1/ R Original Claim ICN 2300 REF Medical Record Number 3 S REF REF01 Reference Identification 2/3 128 R EA REF02 Reference Identification AN 1/ R Medical Record Identification Number 2300 HI Health Care Diagnosis 2 R HI HI01 Health Care Information C022 R HI01-1 List 1/ R BK (ICD-9) Principal Diagnosis ABK (ICD-10) Principal Diagnosis HI01-2 Industry AN 1/ R Principal Diagnosis Note: Cannot be External Cause HI02 Health Care Information C022 R HI02-1 List 1/ R BF (ICD-9) Other Diagnosis ABF (ICD-10) Other Diagnosis HI02-2 Industry AN 1/ R Other Diagnosis Last Updated: 12/8/2017 Page 16 of 40

21 Note: Can be up to 11 HI0x-1 thru HI0x-2 BF/ABF (Other Diagnosis ) elements separated by * 2310A NM1 Referring Provider Name 3 S NM1 NM101 Entity Identifier 2/3 98 R DN NM102 Entity Type R 1 NM103 Name Last or Organization AN 1/ R Name NM104 Name First AN 1/ S NM105 Middle Name AN 1/ S NM108 Identification 1/2 66 S XX = National Provider (NPI) NM109 Identification AN 2/80 67 S NPI 2310A REF Referring Provider Secondary 3 S REF Identification REF01 Reference Identification 2/3 128 R G2 = Provider Medicaid REF02 Reference Identification AN 1/ R Provider Medicaid Last Updated: 12/8/2017 Page 17 of 40

22 2310B NM1 Rendering Provider Name 3 S NM1 NM101 Entity Identifier 2/3 98 R 82 NM102 Entity Type R 1 or 2 NM103 Name Last or Organization AN 1/ R Name NM104 Name First AN 1/ S NM105 Middle Name AN 1/ S NM108 Identification 1/2 66 S XX = National Provider (NPI) NM109 Identification AN 2/80 67 S NPI 2310B PRV Rendering Provider Specialty 3 S PRV Information PRV01 Provider 1/ R PE = Performing PRV02 Reference Identification 2/3 128 R PXC PRV03 Reference Identification AN 1/ R Provider Taxonomy 2310B REF Rendering Provider Secondary 3 S REF Identification Last Updated: 12/8/2017 Page 18 of 40

23 REF01 Reference Identification 2/3 128 R G2 REF02 Reference Identification AN 1/ R Provider Medicaid 2310C NM1 Service Facility Location 3 S NM1 NM101 Entity Identifier 2/3 98 R 77 NM102 Entity Type R 2 NM103 Name Last or Organization AN 1/ S Name NM108 Identification 1/2 66 S XX National Provider Identifier NM109 Service Facility Location AN 2/80 67 S NPI - do not send if same as for Billing Provider N3 Service Facility Location 2 R N3 Address N301 Address Information AN 1/ R N302 Address Information AN 1/ S 2310C N4 Service Location City/State/Zip 2 R N4 Last Updated: 12/8/2017 Page 19 of 40

24 N401 City AN 2/30 19 R N402 State R N403 Zip AN 3/ R 2310C REF Service Facility Secondary 3 S REF Identification REF01 Reference Identification 2/3 128 R LU REF02 Reference Identification AN 1/ R 12 or 14 digit Service Location Identifier ** for Medicare COB information the following segments are required ** 2320 SBR Other Subscriber Information 3 S SBR SBR01 Payer Responsibility Sequence R P Number SBR02 Individual Relationship R 18 SBR03 Reference Identification AN 1/ S Insured Group or Policy Number SBR04 Name AN 1/60 93 S MEDICARE SBR05 Insurance Type 1/ S Last Updated: 12/8/2017 Page 20 of 40

25 SBR09 Claim Filing Indicator 1/ S MB 2320 CAS Claim Level Adjustments 3 S CAS CAS01 Claim Adjustment Group 1/ R PR CAS02 Claim Adjustment Reason 1/ R 1 - for Medicare Deductible CAS03 Monetary Amount R 1/ R Medicare Deductible Amount CAS04 Quantity R 1/ S CAS05 Claim Adjustment Reason 1/ S 2 - Medicare Coinsurance CAS06 Monetary Amount R 1/ S Medicare Coinsurance Amount CAS07 Quantity R 1/ S CAS08 Claim Adjustment Reason 1/ S Psychiatric Reduction 2320 AMT Coordination of Benefits (COB) 3 R AMT Allowed Amount AMT01 Amount 1/3 522 R D Medicare Paid AMT02 Monetary Amount R 1/ R Medicare Paid Amount Last Updated: 12/8/2017 Page 21 of 40

26 2320 OI Other Insurance Coverage 2 S OI Information OI03 Yes/No Condition or Response R Y OI04 Patient Signature Source S P OI06 Release of Information R Y 2330A NM1 Other Subscriber Name 3 R NM1 NM101 Entity Identifier 2/3 98 R IL NM102 Entity Type R 1 or 2 NM103 Name Last or Organization AN 1/ R Name NM104 Name First AN 1/ S NM105 Name Middle AN 1/ S NM108 Identification 1/2 66 R MI NM109 Identification AN 2/80 67 R Medicare Member Last Updated: 12/8/2017 Page 22 of 40

27 2330B NM1 Other Payer Name 3 R NM1 NM101 Entity Identifier 2/3 98 R PR NM102 Entity Type R 2 NM103 Name Last or Organization AN 1/ R MEDICARE Name NM108 Identification 1/2 66 R PI NM109 Identification AN 2/80 67 R MC B DTP Claim Check or Remittance 3 S DTP Date DTP01 Date/Time R 573 DTP02 Date Time Period Format 2/ R D8 DTP03 Date Time Period AN 1/ R Medicare Paid Date CCYYMMDD *** the following segments are for non-medicare COB information 2320 SBR Other Subscriber Information 3 S SBR Last Updated: 12/8/2017 Page 23 of 40

28 SBR01 Payer Responsibility Sequence Number R S SBR02 Individual Relationship R 18 SBR03 Reference Identification AN 1/ S Insured Group or Policy Number SBR04 Name AN 1/60 93 S OTHERINS SBR05 Insurance Type 1/ S SBR09 Claim Filing Indicator 1/ S ZZ 2320 CAS Claim Level Adjustments 3 S CAS CAS01 Claim Adjustment Group 1/ R PR CAS02 Claim Adjustment Reason 1/ R 1 - Other Insurance Deductible CAS03 Monetary Amount R 1/ R Other Insurance Deductible Amount CAS04 Quantity R 1/ S CAS05 Claim Adjustment Reason 1/ S 2 - Other Insurance Coinsurance Last Updated: 12/8/2017 Page 24 of 40

29 CAS06 Monetary Amount R 1/ S Other Insurance Coinsurance Amount 2320 AMT Coordination of Benefits (COB) 3 S AMT Allowed Amount AMT01 Amount 1/3 522 R D Other Insurance Paid AMT02 Monetary Amount R 1/ R Other Insurance Paid Amount 2320 OI Other Insurance Coverage 2 R OI Information OI03 Yes/No Condition or Response R Y OI04 Patient Signature Source S P OI06 Release of Information R Y 2330A NM1 Other Subscriber Name 3 R NM1 NM101 Entity Identifier 2/3 98 R IL NM102 Entity Type R 1 or 2 NM103 Name Last or Organization AN 1/ R Name NM104 Name First AN 1/ S Last Updated: 12/8/2017 Page 25 of 40

30 NM105 Name Middle AN 1/ S NM108 Identification 1/2 66 R MI NM109 Identification AN 2/80 67 R Other Insurance Member 2330B NM1 Other Payer Name 3 R NM1 NM101 Entity Identifier 2/3 98 R PR NM102 Entity Type R 2 NM103 Name Last or Organization AN 1/ R OTHERINS Name NM108 Identification 1/2 66 R PI NM109 Identification AN 2/80 67 R OT B DTP Claim Check or Remittance 3 S DTP Date DTP01 Date/Time R 573 DTP02 Date Time Period Format 2/ R D8 Last Updated: 12/8/2017 Page 26 of 40

31 DTP03 Date Time Period AN 1/ R Other Insurance Paid Date CCYYMMDD ***** 2400 LX Service Line 2 R LX LX01 Assigned Number N0 1/6 554 R 2400 SV1 Professional Service 3 R SV1 SV101 Composite Medical Procedure C003 R Identifier SV101-1 Product/Service R HC SV101-2 Product/Service AN 1/ R SV101-3 Procedure Modifier AN S SV101-4 Procedure Modifier AN S SV101-5 Procedure Modifier AN S SV101-6 Procedure Modifier AN S SV101-7 Description AN 1/ S SV102 Monetary Amount R 1/ R SV103 Unit or Base for Measurement R SV104 Quantity R 1/ R Last Updated: 12/8/2017 Page 27 of 40

32 SV105 Facility AN 1/ S SV107 Composite Diagnosis C004 R Pointer SV107-1 Diagnosis Pointer N0 1/ R SV107-2 Diagnosis Pointer N0 1/ S SV107-3 Diagnosis Pointer N0 1/ S SV107-4 Diagnosis Pointer N0 1/ S SV109 Yes/No Condition Response S SV111 Yes/No Condition Response S SV112 Yes/No Condition Response R SV115 Copay Status S If Medicaid member was exempt from a Co-pay for the service listed use "0" indicator, otherwise do not use this element Last Updated: 12/8/2017 Page 28 of 40

33 2400 CRC Condition Indicator/Durable 3 S CRC Medical Equipment CRC01 Category 2/ R 09 = Durable Medical Equipment Certification CRC02 Certification Condition R N or Y Applies Indicator CRC03 Condition Indicator 2/ R 38 = Certification signed by the physician is on file at the supplier s office ZV = Replacement Item CRC04 Condition Indicator 2/ S 2400 DTP Date Service Date 3 R DTP DTP01 Date/Time R 472 DTP02 Date Time Period Format 2/ R D8 or RD8 DTP03 Date Time Period 1/ R CCYYMMDD or CCYYMMDD-CCYYMMDD 2400 DTP Date Last Certification Date 3 S DTP DTP01 Date/Time R 461 DTP02 Date Time Period Format 2/ R D8 DTP03 Date Time Period 1/ R CCYYMMDD Last Updated: 12/8/2017 Page 29 of 40

34 2410 LIN Drug Identification 3 S LIN When billing a prescribed drug procedure code in 2400, this is required. LIN02 Product/Service R N4 LIN03 Product/Service AN 1/ R National Drug 2410 CTP Drug Pricing 3 S CTP CTP04 Quantity N 1/ R Drug Unit Count CTP05 Composite Unit Of Measure C001 R CTP05-1 Unit or Basis for Measurement R Unit of Measure 2420A NM1 Rendering Provider Name 3 S NM1 NM101 Entity Identifier 2/3 98 R 82 NM102 Entity Type R 1 or 2 NM103 Name Last or Organization AN 1/ R Name NM104 Name First AN 1/ S Last Updated: 12/8/2017 Page 30 of 40

35 NM105 Name Middle AN 1/ S NM108 Identification 1/2 66 R XX = NPI NM109 Identification AN 2/80 67 R NPI 2420A PRV Rendering Provider Specialty 3 S PRV Information PRV01 Provider 1/ R PE PRV02 Reference Identification 2/3 128 R PXC PRV03 Reference Identification AN 1/ R Provider Taxonomy 2420A REF Rendering Provider Secondary 3 S REF Identification REF01 Reference Identification 2/3 128 R G2 REF02 Reference Identification AN 1/ R Provider Medicaid 2420E NM1 Ordering Provider Name 3 S NM1 NM101 Entity Identifier 2/3 98 R DK NM102 Entity Type R 1 - Person Last Updated: 12/8/2017 Page 31 of 40

36 NM103 Name Last or Organization Name AN 1/ R NM104 Name First AN 1/ S NM105 Middle Name AN 1/ S NM108 Identification 1/2 66 S XX = National Provider (NPI) NM109 Identification AN 2/80 67 S NPI 2420E N3 Ordering Provider Address 2 S N3 N301 Address Information AN 1/ R N302 Address Information AN 1/ S 2420E N4 Ordering Provider City, State, 2 R N4 Zip N401 City Name AN 2/30 19 R N402 State or Province 2/2 156 S N403 Postal 3/ S N404 Country 2/3 26 S Last Updated: 12/8/2017 Page 32 of 40

37 N407 Country Subdivision 1/ S 2420E REF Ordering Provider Secondary 3 S REF Identification REF01 Reference Identification 2/3 128 R G2 REF02 Reference Identification AN 1/ R Provider Medicaid 2420E PRV Ordering Provider Specialty 3 S PRV Information PRV01 Provider 1/ R PE = Performing PRV02 Reference Identification 2/3 128 R PXC PRV03 Reference Identification AN 1/ R Provider Taxonomy 2420F NM1 Referring Provider Name 3 S NM1 NM101 Entity Identifier 2/3 98 R DN NM102 Entity Type R 1 NM103 Name Last or Organization AN 1/ R Name NM104 Name First AN 1/ S NM105 Middle Name AN 1/ S Last Updated: 12/8/2017 Page 33 of 40

38 NM108 Identification 1/2 66 S XX = National Provider (NPI) NM109 Identification AN 2/80 67 S NPI 2420F REF Referring Provider Secondary 3 S REF Identification REF01 Reference Identification 2/3 128 R G2 = Provider Medicaid REF02 Reference Identification AN 1/ R Provider Medicaid ***Medicare Adjustment Amounts ** 2430 SVD Line Adjudication Information 3 S SVD SVD01 Identification AN 2/80 67 R MC01 SVD02 Monetary Amount R 1/ R Service Line Medicare Paid Amount SVD03 Composite Medical Procedure C003 R Identifier SVD03-1 Product/Service R HC SVD03-2 Product/Service AN 1/ R Procedure SVD03-3 Procedure Modifier AN S Modifier SVD03-4 Procedure Modifier AN S Modifier Last Updated: 12/8/2017 Page 34 of 40

39 SVD03-5 Procedure Modifier AN S Modifier SVD03-6 Procedure Modifier AN S Modifier SVD03-7 Description AN 1/ S SVD05 Quantity R 1/ R Quantity/Units 2430 CAS Line Adjustment 3 S CAS CAS01 Claim Adjustment Group 1/ R PR CAS02 Claim Adjustment Reason 1/ R 1 Medicare Deductible CAS03 Monetary Amount R 1/ R Medicare Deductible Amount CAS04 Quantity R 1/ S CAS05 Claim Adjustment Reason 1/ S 2 Medicare Coinsurance CAS06 Monetary Amount R 1/ S Medicare Coinsurance Amount CAS07 Quantity R 1/ S CAS08 Claim Adjustment Reason 1/ S 122 Medicare Psychiatric Reduction Last Updated: 12/8/2017 Page 35 of 40

40 CAS09 Monetary Amount R 1/ S Medicare Psychiatric Reduction 2430 CAS Line Adjustment 3 S CAS CAS01 Claim Adjustment Group 1/ R CO CAS02 Claim Adjustment Reason 1/ R Medicare Deductible Denial Reason (Action) CAS03 Monetary Amount R 1/ R Medicare Insurance Deductible Amount 2430 DTP Line Adjudication Date R DTP DTP01 Date/Time A/N 3/3 R 573 DTP02 Date Format AN 2/3 R D8 DTP03 Payment Date N 8 R Medicare Payment Date CCYYMMDD **The following are for reporting other insurance payment information 2430 SVD Line Adjudication Information 3 S SVD SVD01 Identification AN 2/80 67 R OT01 SVD02 Monetary Amount R 1/ R Service Line Other Insurance Paid Amount SVD03 Composite Medical Procedure Identifier C003 R Last Updated: 12/8/2017 Page 36 of 40

41 SVD03-1 Product/Service R HC SVD03-2 Product/Service AN 1/ R Procedure SVD03-3 Procedure Modifier AN S Modifier SVD03-4 Procedure Modifier AN S Modifier SVD03-5 Procedure Modifier AN S Modifier SVD03-6 Procedure Modifier AN S Modifier SVD03-7 Description AN 1/ S SVD05 Quantity R 1/ R Quantity/Units 2430 CAS Line Adjustment 3 S CAS CAS01 Claim Adjustment Group 1/ R PR CAS02 Claim Adjustment Reason 1/ R 1 Other Insurance Deductible CAS03 Monetary Amount R 1/ R Other Insurance Deductible Amount CAS04 Quantity R 1/ S CAS05 Claim Adjustment Reason 1/ S 2 Other Coinsurance Last Updated: 12/8/2017 Page 37 of 40

42 CAS06 Monetary Amount R 1/ S Other Insurance Coinsurance Amount CAS07 Quantity R 1/ S CAS08 Claim Adjustment Reason 1/ S 45 Other Insurance Allowed CAS09 Monetary Amount R 1/ S Other Insurance Allowed Amount 2430 DTP Line Adjudication Date R DTP DTP01 Date/Time A/N 3/3 R 573 DTP02 Date Format AN 2/3 R D8 DTP03 Payment Date N 8 R Other Insurance Payment Date CCYYMMDD TRAILER SE Transaction Set Trailer 2 R SE SE01 Number of Included s N0 1/10 96 R SE02 Transaction Set Control Number AN 4/9 329 R GE Functional Group Trailer 2 R GE GE01 Number of Transaction Sets Included N0 1/6 97 R GE02 Group Control Number N0 1/9 28 R Last Updated: 12/8/2017 Page 38 of 40

43 IEA Interchange Control Number 3 R IEA IEA01 Number of Included Functional Groups N0 1/5 I16 R IEA02 Interchange Control Number N0 9 I12 R Must be identical to the value in ISA13 Last Updated: 12/8/2017 Page 39 of 40

44 837 Professional Claim Idaho MMIS Vendor Specifications Appendix A. Please see Appendix_A_Vendor_Specs-5010.docx. Last Updated: 12/8/2017 Page 40 of 40