837 Professional Health Care Claim. Section 1 837P Professional Health Care Claim: Basic Instructions

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1 Companion Document 837P 837 Professional Health Care Claim This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained in this document are supplemental and should be used in conjunction with the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3) as published by the Washington Publishing Company. Section 1 837P Professional Health Care Claim: Basic Instructions Section 2 837P Professional Health Care Claim: Front End Edits Section 3 837P Professional Health Care Claim: Enveloping Section 4 837P Professional Health Care Claim: Charts for Situational Rules Any questions? Contact E-Solutions LiveChat Page 1 of 20

2 Section 1 - Basic Instructions 1.1 X12 and HIPAA Compliance Checking, and Business Edits EDI interchanges submitted to Anthem for processing pass through compliance edits acknowledgments and reports for accepted/rejected files will be placed in the submitter s trading partner mailbox for pickup. TA1 Interchange Acknowledgment. Anthem returns TA1 X12 and proprietary reports to the submitter of inbound 837 files containing envelope errors in the ISA and GS segments. Level 1. Anthem returns a 999 Interchange Acknowledgment to the submitter for every inbound 837 transaction received. Each transaction passes through edits to ensure that it is X12 compliant. If the X12 syntax or any other aspect of the 837 is not X12 compliant, the 999 will also report the Level 1 errors in AK segments and indicate that the entire transaction set has been rejected. Level 2. When encountering HIPAA compliance (including balancing) and code set errors, Anthem returns: 1) 277 Claims Acknowledgment (CA) and 2) 864 Level 2 Status Report to the submitter identifying which claim(s) have failed. Level 3. In addition to checking for compliance, Anthem applies front end business edits to ensure that the necessary information is populated and complete for efficient processing. Anthem returns the Level 3 Adjudicated Claims Response Report to the submitter identifying which claim(s) have failed. 1.2 HIPAA Compliant Codes Use HIPAA-compliant codes from current versions of the following: Physician s Current Procedure Terminology (CPT) Health Care Financing Administration Common Procedural Coding System (HCPCS) International Classification of Diseases Clinical Mod (ICD-10-CM) Diseases Provider Taxonomy Codes National Drug Code 1.3 Diagnosis Codes According to the 837P TR3, a transaction is not X12 compliant if decimal points are used in diagnosis codes. Therefore, should a diagnosis code contain a decimal point, Anthem will return a 999 to the submitter indicating that the transaction has been rejected. 1.4 Procedure Codes and Modifiers All valid CPT and HCPCS codes and modifiers are accepted for claim adjudication. Refer to your billing guidelines or provider contract for submission of these codes. If submitted codes are invalid, a 277CA and an 864 Level 2 Status Report will be returned to the submitter identifying which claim(s) have failed. 1.5 Uppercase Letters, Special Characters, and Delimiters As specified in the TR3, the basic character set includes uppercase letters, digits, spaces, and other special characters. All alpha characters must be submitted in UPPERCASE letters only. Page 2 of 20

3 Suggested delimiters for the transaction are assigned as part of the trading partner set up. EDI Representative will discuss options with trading partners, if applicable. Inbound Delimiters Suggested Value Data Element Separator * Asterisk Sub-Element Separator : Colon Segment Terminator ~ Tilde Repetition Separator ^ Caret To avoid syntax errors, hyphens, parentheses and spaces are not recommended to be used in values for identifiers. Examples: Recommended: Zip Code Medical Record # Since originally submitted values may be returned on outbound transactions, Anthem encourages trading partners to not use the following special characters as part of the value: asterisk (*), less than/greater than signs (<, >), colon (:), and slash (/). This minimizes the risk for a special character to be recognized as a delimiter. Example: Provider assigns a Patient Control Number 12* Although an asterisk (*) is a valid special character, it adversely affects processing since it is also a common delimiter. The value 12* may process incorrectly as two separate values 12 and Decimal R Data Element Types R data element types contain a decimal point; involving monetary amounts, units, visits, weights, and frequency. Anthem recommends using decimal points for monetary amounts, and whole numbers for other types of R data elements. Except for monetary amounts, if R data element type includes a decimal and numbers after the decimal, Anthem adjudicates the claim based on the whole number. Numbers after the decimal will not be considered. 1.7 Numeric Values, Monetary Amounts and Units Anthem pays all claims in US dollars and therefore, accepts monetary amounts in US dollars only. If codes related to foreign currencies are used, then a 277CA and an 864 Level 2 Status Report will be returned to the submitter identifying which claim(s) have failed. Anthem recognizes units in whole numbers only. If a negative service line charge (SV102) or negative units (SV104) are used, then a 277CA and an 864 Level 2 Status Report will be returned to the submitter identifying which claim(s) have failed. 1.8 Address Information P.O. mailboxes / Lock Boxes are not allowed in the Billing Provider loop. If submitted in the Billing Provider loop, a 277CA and an 864 Level 2 Status Report will be returned to the submitter identifying which claim(s) have failed. The Pay-to Address loop does support P.O. Box / Lock Box addresses. Therefore, if payment is expected to be remitted to a P.O. Box / Lock Box, submit the P.O. Box / Lock Box address. Full 9-digit zip codes are required in the Billing Provider and Service Facility Location loops. If 5-digit zip codes are used in these loops, a 277CA and an 864 Level 2 Status Report will be returned to the submitter identifying which claim(s) have failed. Page 3 of 20

4 1.9 Taxonomy Codes (PRV) The Healthcare Provider Taxonomy code set divides health care providers into hierarchical groupings by type, classification, and specialization, and assigns a code to each grouping. The Taxonomy consists of two parts: individuals (e.g., physicians) and non-individuals (e.g., ambulatory health care facilities). All codes are 10-alphanumeric positions in length. Health care providers select the taxonomy code(s) that most closely represents their education, license, or certification. If a health care provider has more than one taxonomy code associated with it, a health plan may prefer that the health care provider use one over another when submitting claims for certain services. It is strongly recommended that the taxonomy be populated in PRV segments for all applicable claims that you are filing. Refer to the CMS website for a listing of codes, Filing Electronic Claims with Adjustment Information Submitting claims for charges not included on a prior claim is done using claim frequency codes. When submitting adjustments noted with claim frequency code 5, 7, or 8, populate Loop 2300 REF02 Payer Claim Control Number (from the 835, Provider Remittance Voucher, or 835 Supplement on Point of Care). Without this original Anthem internal tracking number, adjustment request cannot be completed. Anthem only accepts claim frequency codes 5, 7, and 8. Claims with frequency codes other than for late charges, to replace a prior claim, or void a prior claim will be rejected and identified on the L3 Adjudicated Claims Response Report Coordination of Benefits Specific 837 data elements work together to coordinate benefits between Anthem and Medicare or other carriers. Following the Provider-to-Payer-to-Provider model; Code 5 Late Charge(s) 7 Replacement of Prior Claim 8 Void/Cancel of Prior Claim Claim Frequency Code (Loop 2300 CLM05-3) Description Filing Instructions Action Use to submit additional charges for the same dates of service (statement covers period) as a previous claim. Use to replace an entire claims (all but identity information). Use to entirely eliminate a previously submitted claim for a specific provider, patient, payer, insured, and statement covers period. File electronically, as usual. Include only the additional late charges that were not included on the original claim. File electronically, as usual. File the claim in its entirety, including all services for which you are requesting consideration. File electronically, as usual. Include all charges that were on the original claim. Anthem will add the late charges to the previously processed claim. Anthem will consider the original claim null and void, and Anthem will void the original claim from records based on request. Claim is identified as inquiry on the L3 report and 151 response is sent to provider. The provider sends the 837 to the primary payer. The primary payer adjudicates the claim and sends an 835 Payment Advice to the provider. The 835 includes the claim adjustment reason code and/or remark code for the claim. Upon receipt of the 835, the provider sends a second 837 with COB information populated in Loops 2320, 2330A-G, and/or 2430 to the secondary payer. The secondary payer adjudicates the claim and sends an 835 Payment Advice to the provider. Page 4 of 20

5 Anthem recognizes submission of an 837 transaction to a sequential payer populated with data from the previous payer s 835. Based on the information provided and the level of policy, the claim may be adjudicated without the paper copy of the Explanation of Benefits from Medicare or the primary carrier. When more than one payer is involved on a claim, data elements for all prior payers must be present (i.e., if a tertiary payer is involved, then all the data elements from the primary and secondary payers must also be present). If data elements from previous payer(s) are omitted, Anthem will fail the particular claim. Since 5010 has made changes to COB reporting, Anthem strongly encourages in-depth review of TR3 front matter. Anthem adjudicates and pays professional services at the line level. Therefore, when Anthem has any payment position other then primary, line level payments (SVD02), and line level adjustments (CAS), must be conveyed, when known by the submitter Other COB Allowed Amount - Calculation The allowed amount is calculated using the service line charge and any applicable adjustments: Total Line Charge (Loop 2400 SV102) minus any monetary amount (Loop 2430 CAS03) at each service line that is not associated to deductible, co-insurance, and co-payment (Loop 2430 CAS02 adjustment reason codes 1, 2, and 3 ). If no adjustments are present in Loop 2430 CAS, then the Total Line Charge is the allowed amount Claim and COB Balancing For COB claims, balancing is performed at both claim and service line on the payment charges for each payer. If not balanced, a 277CA and an 864 Level 2 Status Report will be returned to the submitter identifying which claim(s) have failed. Loop 2300 CLM02 (Total Claim Charge) must equal the sum of Loop 2400 SV102 (Line Item Charge). Loop 2320 AMT02 (COB Payer Paid Amount) must equal the sum of Loop 2430 SVD02 (Line Adjudication Information) less the sum of Loop 2300 CAS (Claim Level Adjustments). Loop 2400 SV102 (Line Item Charge Amount) must equal the sum of Loop 2430 SVD02 (Line Adjudication Information) plus the sum of Loop 2430 CAS (Claim Level Adjustments). Page 5 of 20

6 1.14 Preparing Unsolicited Attachments to Support a Claim (Loop 2300 PWK) Loop 2300 PWK segment is required when paper documentation (attachments) supports a claim. If sending attachment electronically (PWK02=EL) and using Medical Electronic Attachment vendor (MEA), enter prefix MEA and all alpha/numeric characters assigned as your tracking number (ex. MEA12345B) to become the Attachment Control Number (PWK06). If sending attachment by mail or by fax (PWK02=BM, FX), prepare a 151 Claim Information/ Adjustment Request (151) for each patient and claim requiring supporting documentation. The 151 is available from 1) VA Portal, or 2) VA > communications > answers & anthem > provider forms > 151. Complete the fields on the 151. Note that the attachment control # must be a unique identifier for each attachment claim constructed using the NPI, Member ID #, and date of service. Attachment Control Number YTA XXXXXXX National Provider Identifier (NPI) = Member ID # including prefix from ID card = YTA Date of Service (MMDDCCYY format) = Distinctive Provider-assigned Sequence # (OPTIONAL) = XXXXXXXXXX The claim and supporting documentation matches based on the attachment control number. If the number is not used, the claim may be denied. Multiple attachments to support a single claim use the same attachment control number and identified on the 151 with multiple documents attached. Illegible information will delay processing. If claim with supporting documentation is rejected, correct the claim using the same attachment control number. Anthem will hold the attachment and match the claim once it is received. However, if a new attachment control number is assigned for the retransmission of the claim, supporting documentation referencing the new attachment control number will need to be submitted Sending Unsolicited Attachments to Support a Claim Mail the attachment(s) the day before or the day the claim is submitted Do not send a copy of the claim with the attachment Do not send unnecessary attachments (i.e., do not send a copy of the member s ID card) Attach the 151 with the supporting documentation. If you send by mail or fax, include the attachment control # (matched on the 151) in the upper right hand corner of the supporting documentation. Mailing Address: Anthem BCBS P.O. Box Richmond, VA Fax Number: (804) Page 6 of 20

7 1.16 Claim Note (Loop 2300 NTE) and Line Note (Loop 2400 NTE) When appropriate, if supplemental information can be conveyed in 2400 bytes or less, use the NTE segments rather than sending attachments (PWK). If a Claim Note requires more than 1600 bytes, you may continue it in the allotted 800 bytes of the Line Note segment and vice versa. This continuation from Claim Note to Line Note, and Line Note to Claim Note, is called overflow. Unlisted or Non-Specific Supplies and Equipment - When appropriate, include the manufacturer s description of the supply or equipment in the Line Note segment. Include Only Pertinent Information in NTE segments - In NTE segments, include only pertinent information. Information such as Anthem Blue Cross and Blue Shield, the name of the other insurance carrier or not a duplicate, may delay processing. Procedure or Service Unlisted or non-specific drug codes supplies and equipment surgery and maternity procedure(s) radiology procedure(s) pathology and laboratory procedure(s) other services or procedures not specifically listed as requiring attachments infusion therapy codes Attachment and Notes (PWK and NTE) Supporting Notes and/or Attachments Literal description of the drug and the dosage in Loop 2400 NTE, and the corresponding NDC (National Drug Code) Number(s) in Loop 2410 LIN03. Manufacturer's description of the supply or equipment. Operative report A complete description of the service or procedure. Attach x-ray report as applicable. A complete description of the service or procedure. Attach pathology and/or lab report as applicable. Complete description of the service or procedure. Plan of treatment (refer to your provider agreements for billing guidelines which identify what information you should include within the plan of treatment.) Modifier GQ via asynchronous telecommunications Attach records from the encounter. KR rental item, billing for partial month First and last dates of rental MS Note: services applicable to this modifier require pre-authorization from Case Management. 6 mo. maintenance and servicing fee; Attach individual case management authorization agreement. parts and labor not covered under supplier warranty. QF prescribed amount of oxygen exceeds Attach the medical report. 4 liters per minute and portable oxygen is prescribed QG prescribed amount of oxygen is Attach the medical report. greater than 4 liters per minute 21 prolonged evaluation and Attach office or hospital progress notes and document additional management services time spent. 22 unusual procedural service Attach the medical or surgical report and/or an explanation for using this modifier. 23 unusual anesthesia Attach the anesthesia report and an explanation for using this modifier. 62 two surgeons Attach the operative report. Bills and operative reports from all surgeons are required to complete processing. 63 procedure performed on infant less Attach the medical/surgical report and/or an explanation for using than 4 kg this modifier. 66 surgical team Attach the operative report. Bills and operative reports from all surgeons are required to complete processing. Other medical supplies and equipment Certain services such as orthotics, DME, and prosthetics may require necessity documentation when pre-authorization has not been obtained. Include the patient's history, physical exam, diagnosis, the manufacturer's description of the supply, and manufacturer's cost (after rebates and discounts). Air / Ground ambulance When pre-authorization has not been obtained, a copy of the trip report is necessary. Page 7 of 20

8 1.17 Medicaid Reclamation / Subrogation Claims (BHT06 = 31) Situations exist when a Patient who has BCBS as primary and Medicaid as secondary (last payer), indicates to the provider that he has Medicaid insurance only. The service is rendered and the provider bills Medicaid as primary. Medicaid pays the claim as the sole payer ( pays out of turn ) and later determines that the patient actually had primary insurance. In order to reclaim monies, states submit claims to the primary insurance after reconciliation of eligibility files between BCBS and Medicaid. Exempt from NPI, trading partners on behalf of states must submit specific data elements in Loops 2010AA, 2010AC, 2010BB, 2310B, 2310C and 2430 for Medicaid reclamation Dental Services Dental services requiring CPT codes and/or modifiers must be submitted as a professional claim in the 837P format. The following chart details the types of service that should be submitted in 837P format versus the 837D format. Professional vs. Dental Services Provider Service Code Type Format Dentists and Oral Surgeons Dental services to prepare mouth for radiation therapy to treat head and neck cancers. These include: CDT* 837P** Dental Oral Exam Weekly follow-up visits (6) to manage Oral Use Panelipse X-ray oral side effects surgeons appropriate Bitewing X-rays (4) Simple Extractions may use ICD-10 Periapical X-rays (per film) Surgical Extractions Current head/ Oral Prophylaxis Alveoplasty in conjunction with Procedure neck cancer Quad Scale (per quadrant) extractions (per quadrant) Terminology diagnosis Maxillary Fluoride Trays Tori Removal (CPT) for code.**** Mandibular Fluoride Trays Radiation Therapy Appliance surgical Amalgam Restorations procedures. Oral Surgeons Non-surgical services related to removal of impacted wisdom teeth CPT and/or 837P** All other surgical or medical services HCPCS* Dentists All other dental services CDT* 837D Oral Surgeons Surgical removal of impacted wisdom teeth CDT* 837D*** * CDT codes are available in both Current Dental Terminology from the American Dental Association (ADA) and Health Care Procedure Coding System (HCPCS) from the Center for Medical and Medical Services (CMS). ** Tooth Number and Tooth Surface are not required. *** Tooth Number and Tooth Surface are required. **** ICD-10 codes are available from International Classification of Diseases Manual. Page 8 of 20

9 Section 2 - Front End Edits Business editing performed to check for data validity (for Anthem processing), data compatibility, and formatting. If error encountered, it is reported via the L3 Claims Adjudication Response report. Code 837P Error Codes for Rejected/Failed Claims Business Pre-Adjudication Edits Level 3 Adjudicated Claims Response Report Description/Resolution E0006 SUBSCRIBER NOT FOUND Submit valid member ID E0038 INVALID PROVIDER NUM Submit 6-position alphanumeric; not all zeroes/nines/alpha Only 3rd or 4th position may contain alpha character E0051 INVALID NAME Submit only A-Z, spaces, asterisks, hyphens and apostrophes 1st position must be alpha character E0055 INVALID STATE Submit valid state code per state/location table E0063 INVALID PROCEDURE CODE Submit valid procedure code for claim service line E0117 INVALID NUMBER Must be populated when procedure code is populated Number of days cannot be greater than difference between LAST and FIRST DATES Number 001 E0124 INVALID CODE Valid podiatry modifier: TA, T1-T9, WF, WZ, ZF Submit valid claim filing indicator Submit valid diagnosis code (includes those with HB, RP, PA, IV, VC, SSO, SSY, SSN) Valid Medicare Acceptance code: Y, N Valid NDC #: max length is 11 characters with no hyphens Valid orthodontic treatment period: Valid procedure code must be 5-position alphanumeric Valid provider # must be 6-position alphanumeric with no blanks Valid patient status code: Discharge date must be absent for patient status code Valid gender code: F, M E0125 INVALID AMOUNT Amount must be all numeric Ensure Medicare Deductible Amount < Total Claim Charge Amount Ensure COB Allowed Amount < Total Claim Charge Amount COB Allowed Amount must be populated when COB Paid Amount is present Ensure COB Paid Amount < COB Allowed Amount Ensure Paid Amount < Total Claim Charge Amount E0126 INVALID DATE Ensure Current Date Date fields If Ortho Indicator = Y, valid date First Appliance Date Ensure Consultation Date First Date Ensure Consultation Date Onset/LastMenstrualPeriod/Accident Date Ensure Last Date First Date Submit Date of Birth for patient age 100 by adding 2 to current year (i.e., DOB 1887, current year > submit 1999) Page 9 of 20

10 Code 837P Error Codes for Rejected/Failed Claims Business Pre-Adjudication Edits Level 3 Adjudicated Claims Response Report Description/Resolution E0187 NUMBER CONFLICT Submit valid number of tooth (i.e., 001, 002, 003 ) For range of teeth, ensure number = number of teeth in range E0222 INVALID FST DT Ensure First Date Date of Birth E0296 INVALID PROCEDURE POS must be valid for the Procedure Code TOS must be valid for this Procedure Code E0446 PROV PAY TO ONLY Submit individual ID number of provider who rendered the service E0522 AGE/ICD9 CONFLICT Diagnosis Code must be age-appropriate E0523 SEX/ICD9 CONFLICT (CANCEL: 7/8/16) Diagnosis Code must be gender-appropriate E0538 DIAGNOSIS NOT FOUND Valid Diagnosis Code contains 2 position alpha codes: NB, RP, PA, IV, VC or 3 position alpha codes SSO, SSY, SSN E0756 SEX/SVCD CONFLICT (CANCEL: 7/8/16) Procedure Code must be gender-appropriate E0757 AGE/SVCD CONFLICT Procedure Code must be appropriate for age range of patient E0803 INVALID SURG DATE Ensure Last Date = First Date for surgical procedures E3069 INVALID MODIFIER Submit valid modifier E4130 INVALID PAT LAST NAME Submit only A-Z, spaces, asterisks, hyphens and apostrophes E4131 INVALID BIRTH DATE Ensure Birth Date Current Date E4134 INVALID ACCIDENT/ONSET DATE Ensure Accident/Onset Date Date of Service (start) Ensure Accident/Onset Date Date of Birth Ensure Accident/Onset Date Current Date E4158 INVALID FROM DOS Ensure Date of Service Date of Birth Ensure Date of Service Current Date Ensure Range of dates of service < 365/366 days E4159 INVALID POS Submit valid HCFA or IPDR code E4160 INVALID PROCEDURE CODE Procedure Code/ CPT4 or HCPC Code is invalid E4161 INVALID DIAGNOSIS CODE Submit at least one diagnosis code E4209 INVALID PAT FIRST NAME Submit only A-Z, spaces, asterisks, hyphens and apostrophes E4210 INVALID THRU DOS Ensure Date of Service Date of Birth Ensure Date of Service Current Date Ensure Range of dates of service < 365/366 days Page 10 of 20

11 Code 837P Error Codes for Rejected/Failed Claims Business Pre-Adjudication Edits Level 3 Adjudicated Claims Response Report Description/Resolution E4412 DEP NOT FOUND Dependent Information is not on file E4479 REPORT TYPE CODE REQUIRED Submit explanation of benefits (PWK01=EB) or other payer information (Loop 2320, 2330A, 2330B) E4481 ORIGINAL REFERENCE NUMBER REQUIRED Submit number if claim frequency code is 5, 6, 7, or 8 E4485 INVALID REPORT TRANSMISSION CODE Do not submit 'EM' or 'FT' E4489 INVALID CONSULT DATE Ensure Consult Date Date of Birth Ensure Consult Date Onset Date E4490 INVALID DISCHARGE DATE Ensure Discharge Date Date of Birth Ensure Discharge Date Date of Admission E4491 INVALID LINE ADJUSTMENT Ensure each occurrence line charge E4492 INVALID DEDUCTIBLE CAS01 = 'OA' or 'PR' Ensure each occurrence (CAS01=OA, CAS02=1) total claim charge E4493 INVALID COB OTHER PAID AMOUNT Submit CAS segment (Loop 2320 or 2430) or PWK segment (Loop 2300) 'EB' when SBR01 not 'P' and Payer Prior Payment present E4500 NARRATIVE OR PWK REQUIRED Submit narrative or attachment for procedure codes ending in '99' E4501 MODIFIER NEEDS ATTACHMENT Submit attachment for modifiers GQ, MS, GF, QG, 21, 22, 23, 62, 66 Submit attachment/narrative for modifier KR E4502 INVALID TOTAL CHARGE AMOUNT Ensure Total Charge Amount > 0 for original claims E4508 COB TOTAL NON COVERED When submitted, ensure 1) SBR01 not 'P'; 2) Other Subscriber Claim Filing Indicator qualifier not 'MA' or 'MB'; 3) Other Sub Claim Filing Indicator qualifier 'ZZ' and code = spaces; and 4) PWK Supplemental Report Type Code = 'EB' E4509 INVALID PROCEDURE CODE QUALIFIER Do not submit qualifier 'WK' E4538 CLM FILED WRONG PLAN Submit claim for ancillary services to the appropriate service local plan E4539 ORDERING NPI Submit claim for ancillary services with ordering provider name and NPI E4540 REFERRING NPI Submit claim for ancillary services with referring provider name and NPI E4541 SVCS NOT COVERED Medicaid Reclamation Only All service lines contain Procedure code starting with H, T or G0307, G9016, G9006, G9008, G9007, G9006, G9002, G0124, G9001 E4542 CLM FILED WRONG PLAN Medicaid Reclamation Only Member ID is not within the VA Service area E4566 POSSIBLE REL CODE CONFLICT Relationship Code does not match information on file for the claimant with this name Page 11 of 20

12 Code 837P Error Codes for Rejected/Failed Claims Business Pre-Adjudication Edits Level 3 Adjudicated Claims Response Report Description/Resolution E4606 OTHER INSURANCE PAID AMOUNT SUBMITTED WITH A NEGATIVE AMOUNT Other Insurance Paid Amount was submitted with a negative amount; please correct and resubmit for consideration E4607 SERVICE LINE BILLED WITH ANESTHESIA CODE REQUIRING MODIFIER Service Line was billed with anesthesia procedure code that requires a modifier for consideration. Please correct, resubmit a valid modifier with the anesthesia procedure code for consideration. E4610 SERVICE LINE BILLED WITH ANESTHESIA CODE REQUIRING ANESTHESIA MODIFIER(S) Service Line was billed with anesthesia procedure code and requires anesthesia modifier(s) based on Billing Guidelines. Please review anesthesia procedure code and resubmit with a valid anesthesia modifier ( AA, AD, G8, G9, P1, P2, P3, P4, P5, P6, QK, QS, QX, QY, QZ, 23, 47) for consideration.code for consideration. Page 12 of 20

13 Section 3 - Enveloping EDI envelopes control and track communications between you and Anthem. One envelope may contain many transaction sets grouped into the following: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) 837 Professional Health Care Claim Envelope Specific to Anthem (TR3, Appendix C) ISA Interchange GS Functional Group GE Functional Group IEA Interchange Control Header Header Trailer Control Trailer ISA01 00 GS01 HC GE01 refer to TR3 IEA01 refer to TR3 ISA02 refer to TR3 GS02 SENDER ID GE02 refer to TR3 IEA02 refer to TR3 ISA03 00 EDI assigned ISA04 refer to TR3 Left-justified followed by ISA05 ZZ no zeroes or spaces ISA06 SENDER ID EDI assigned GS CMSCOS Left-justified GS04 refer to TR3 followed by spaces GS05 refer to TR3 GS06 refer to TR3 ISA07 ZZ GS07 X ISA08 ANTHEM GS08 ISA09 refer to TR3 ISA10 refer to TR3 ISA11 ^ (5E) ISA NOTE. Critical Batching and Editing Information ISA13 refer to TR3 *Transactions must be batched in separate functional group by GS03. ISA14 refer to TR3 *Unique group control number (GS06) MUST NOT be duplicated d within 365 days ISA15 refer to TR3 by Trading Partner ID (GS02); files containing duplicate or previously received ISA16 refer to TR3 group control numbers will be rejected. 837 Professional Health Care Claim Envelope Specific to Anthem Medicaid Reclamation (TR3, Appendix C) ISA Interchange GS Functional Group GE Functional Group IEA Interchange Control Header Header Trailer Control Trailer ISA01 00 GS01 HC GE01 refer to TR3 IEA01 refer to TR3 ISA02 refer to TR3 GS02 SENDER ID GE02 refer to TR3 IEA02 refer to TR3 ISA03 00 EDI assigned ISA04 refer to TR3 Left-justified followed by ISA05 ZZ no zeroes or spaces ISA06 SENDER ID EDI assigned GS03 MEDICAIDRECVA Left-justified GS04 refer to TR3 followed by spaces GS05 refer to TR3 GS06 refer to TR3 ISA07 ZZ GS07 X ISA08 MEDICAIDREC GS08 ISA09 refer to TR3 ISA10 refer to TR3 ISA11 ^ (5E) ISA NOTE. Critical Batching and Editing Information ISA13 refer to TR3 *Transactions must be batched in separate functional group by GS03. ISA14 refer to TR3 *Unique group control number (GS06) MUST NOT be duplicated within 365 days ISA15 refer to TR3 by Trading Partner ID (GS02); files containing duplicate or previously received ISA16 refer to TR3 group control numbers will be rejected. Page 13 of 20

14 Section 4 - Charts for Situational Rules TR3 Listed below are loops, segments, and data elements required for proper adjudication by Anthem per the situational rules in the 837P TR3. Segment 837 Professional Health Care Claim Reference Designator(s) Value P.70 ST Transaction Set Header ST03 Implementation Convention Ref P.71 BHT BHT06 CH Beginning of Transaction Type 31 Hierarchical Trx Code Loop ID 1000A Submitter Name P.74 NM1 NM109 (Submitter Submitter Name Identification Code Identifier) UPPERCASE P.76 PER Submitter EDI Contact Information - Refer to TR3 Loop ID 1000B Receiver Name P.79 NM1 NM103 Receiver Name Last Name or Organization Name NM109 Identification Code Definitions and Notes Specific to Anthem - Health Care Claim, Professional All submissions recognized as chargeable. required for Medicaid Reclamation EDI assigned Sender ID. Equals the value entered in ISA06 and GS02. ANTHEM HEALTH PLANS OF VIRGINIA INC - represents Receiver Name CMSCOS - Code represents Anthem Health Plans of Virginia, Inc. (DUNS with suffix) Loop ID 2000A Billing Provider Hierarchical Level P.81 HL Billing Provider Hierarchical Level - Refer to TR3 P.83 PRV PRV03 (Provider It is strongly encouraged to enter the Billing Provider Reference Taxonomy taxonomy code to uniquely identify the Specialty Info Identification Code) provider. P.84 CUR CUR02 USD USD - US dollars Foreign Currency Currency Code Monetary amounts recognized in US dollars Information only. Loop ID 2010AA Billing Provider Name P.87 NM1 NM103 Billing Provider Last Name or Enter the provider name noted on the W-9 (Request for taxpayer Name Organization Name Identification Number and Certification). P.91 N3 N301 (Billing Billing Provider Address Provider Enter the physical address to uniquely identify Address Information Address Line) the provider. Submitting PO Box/Lock Box address will result in claim failure, and return of 277CA and Level 2 Status report. P.92 N4 Billing Prov City, State, ZIP Code - Refer to TR3 P.94 REF REF02 (Billing Billing Provider Tax Reference Provider Tax Identification # Identification Identification #) P.96 REF Billing Provider UPIN/License Information - Refer to TR3 P.98 PER Billing Provider Contact Information - Refer to TR3 Loop ID 2010AB Pay-To Address Name P.101 NM1 Pay-to Address Name - Refer to TR3 P.103 N3 N301 (Pay-to Enter the address to uniquely identify the Pay-to Address Address Provider provider. If payment expected to be remitted Information Address Line) to PO Box/Lock Box, submit in Pay-to loop. P.104 N4 Pay-To Address City, State, ZIP Code - Refer to TR3 *Although loops, segments and/or data elements required for Medicaid Reclamation are clarified in the definition and notes as, they are not exclusive to Medicaid Reclamation type of claims only. Page 14 of 20

15 837 Professional Health Care Claim TR3 Segment Reference Designator(s) Value Definitions and Notes Specific to Anthem Loop ID 2010AC Pay-To Plan Name P.106 NM1 Pay-to Plan Name NM103 Name Last or Organization Name (Pay-to Plan Organizational Name) P.108 N3 P.109 N4 P.111 REF Pay-to Plan Address - Refer to TR3 Pay-to Plan City, State, ZIP Code - Refer to TR3 Pay-to Plan Secondary Identification - Refer to TR3 P.113 REF Pay-to Plan Tax Identification # REF02 Reference Identification (Pay-to Plan Tax Identification #) Loop ID 2000B Subscriber Hierarchical Level P.114 HL P.116 SBR P.119 PAT Subscriber Hierarchical Level - Refer to TR3 Subscriber Information - Refer to TR3 Patient Information - Refer to TR3 Loop ID 2010BA Subscriber Name P.121 NM1 Subscriber Name NM109 Identification Code ***ALL ALPHA CHARACTERS MUST BE IN UPPERCASE LETTERS. Enter the ID Number exactly as it appears on the front of the ID card, including ANY PREFIX. Enter format: Example Format Explanation XXX XXXX XXX999X99999 YTA ALTJ YTA123X character alphanumeric prefix (uppercase) followed by 9-character alphanumeric subscriber ID code. R R R (uppercase) followed by 8-position numeric subscriber ID code. P.124 N3 P.125 N4 P.127 DMG P.129 REF P.130 REF P.131 REF Subscriber Address - Refer to TR3 Subscriber City, State, ZIP Code - Refer to TR3 Subscriber Demographic Information - Refer to TR3 Subscriber Secondary Identification - Refer to TR3 Property and Casualty Claim Number - Refer to TR3 Property and Casualty Subscriber Contact Information - Refer to TR3 Loop ID 2010BB Payer Name P.133 NM1 Payer Name NM103 Payer Name ANTHEM HEALTH PLANS OF VIRGINIA INC - represents Payer NM108 PI PI - Payer Identification ID Code Qualifier NM109 Identification Code (Payer Primary Identifier) CMSCOS P.135 N3 P.136 N4 P.138 REF Payer Address - Refer to TR3 Payer City, State, ZIP Code - Refer to TR3 Payer Secondary Identification - Refer to TR3 P.140 REF REF01 G2 G2 - Provider Commercial Number Billing Provider Ref ID Qualifier Secondary Identification REF02 Ref Identification (Billing Prov Secondary ID) Loop ID 2000C Patient Hierarchical Level P.142 HL P.144 PAT Patient Hierarchical Level - Refer to TR3 Patient Information - Refer to TR3 *Although loops, segments and/or data elements required for Medicaid Reclamation are clarified in the definition and notes as, they are not exclusive to Medicaid Reclamation type of claims only. Page 15 of 20

16 837 Professional Health Care Claim TR3 Segment Reference Designator(s) Value Definitions and Notes Specific to Anthem Loop ID 2010CA Patient Name P.147 NM1 P.149 N3 P.150 N4 Patient Name - Refer to TR3 Patient Address - Refer to TR3 Patient City, State, ZIP Code - Refer to TR3 P.152 DMG Patient Demographic Information - Refer to TR3 P.154 REF Property and Casualty Claim Number - Refer to TR3 P.155 REF Property and Casualty Patient Contact Information - Refer to TR3 Loop ID 2300 Claim Information P.157 CLM CLM01 (Patient Maximum of 20 alphanumeric characters. Claim Information Claim Submitter's Account Value is returned on outbound 835 and Identifier Number) other transactions. CLM02 (Total Claim Value must equal the sum of submitted Monetary Amount Charge Amt) service line charges in Loop 2400 SV102. CLM05-3 5, 7, 8 If '5' (late charges), '7' (replacement) or '8' Claim Frequency (void/cancel) then the Payer Claim Control # Type Code is required and must contain Anthem's originally assigned claim number. P.164 DTP Date - Onset of Current Illness or Symptom - Refer to TR3 P.165 DTP Date - Initial Treatment Date - Refer to TR3 P.166 DTP Date - Last Seen Date - Refer to TR3 P.167 DTP Date - Acute Manifestation - Refer to TR3 P.168 DTP Date - Accident - Refer to TR3 P.169 DTP Date - Last Menstrual Period - Refer to TR3 P.170 DTP Date - Last X-ray Date - Refer to TR3 P.171 DTP Date - Hearing and Vision Prescription Date - Refer to TR3 P.172 DTP Date - Disability Dates - Refer to TR3 P.174 DTP P.175 DTP P.176 DTP P.177 DTP P.178 DTP P.180 DTP P.181 DTP Date - Last Worked - Refer to TR3 Date - Authorized Return to Work - Refer to TR3 Date - Admission - Refer to TR3 Date - Discharge - Refer to TR3 Date - Assumed and Relinquished Care Dates - Refer to TR3 Date - Property and Casualty Date of First Contact - Refer to TR3 Date - Repricer Received Date - Refer to TR3 BM - By Mail P.182 PWK PWK02 BM Report AA Transmission Code FX Claim Supplemental Information PWK06 Identification Code AA - Available on Request at Provider Site FX - By Fax EL - Electronic attachment EL Providers using MEA for claims attachment, enter "MEA" and all alpha/numeric characters assigned as your tracking number. (Ex: MEA12345B) Providers using mail/fax, submit the 151 Adjustment Request Form with the supporting documentation. P.186 CN1 Contract Information - Refer to TR3 P.188 AMT Patient Amount Paid - Refer to TR3 P.189 REF Service Authorization Exception Code - Refer to TR3 P.191 REF Mandatory Medicare Crossover Indicator - Refer to TR3 P.192 REF Mammography Certification Number - Refer to TR3 P.193 REF Referral Number - Refer to TR3 P.194 REF Prior Authorization ti - Refer to TR3 Page 16 of 20

17 TR3 Segment Reference Designator(s) Loop ID 2300 Claim Information (cont'd) P.196 REF REF01 Payer Claim Ref ID Qualifier Control Number REF02 Reference Identification F8 Value (Claim Original Reference Number) P.197 REF P.199 REF P.200 REF P.201 REF CLIA Number - Refer to TR3 Repriced Claim Number - Refer to TR3 Adjusted Repriced Claim Number - Refer to TR3 Investigational Device Exemption Number - Refer to TR3 P.202 REF REF01 D9 P.204 REF P.205 REF P.206 REF P.207 K3 NTE Claim ID for Transmission Intermediaries 837 Professional Health Care Claim Ref ID Qualifier REF02 Reference Identification (Value Added Network Trace Number) Medical Record Number - Refer to TR3 Demonstration Project Identifier - Refer to TR3 Care Plan Oversight - Refer to TR3 File Information - Refer to TR3 P.209 NTE02 Notes beyond 80 bytes overflow to Loop 2400 NTE02. Also, Claim Note Claim Note Text field reserved for overflow from Loop 2400 NTE02. P.211 CR1 P.214 CR2 P.216 CRC P.219 CRC P.221 CRC P.223 CRC Ambulance Transport Information - Refer to TR3 Spinal Manipulation Service Information - Refer to TR3 Ambulance Certification - Refer to TR3 Patient Condition Information: Vision - Refer to TR3 Homebound Indicator - Refer to TR3 EPSDT Referral - Refer to TR3 ICD-10-CM Guide requires diagnosis codes to the highest level of specificity. P.226 HI Health Care Diagnosis Code - Refer to TR3 P.239 HI Anesthesia Related Procedure - Refer to TR3 P.242 HI Condition Information - Refer to TR3 P.252 HCP Claim Pricing/Repricing Information - Refer to TR3 Definitions and Notes Specific to Anthem F8 - Original Reference Number Represents the claim # assigned by Anthem. Providers should submit the original claim # indicated on the 835 when Loop 2300 CLM05-3 equals values of '5', '7' or '8'. D9 - Claim Number Will be returned on Level 2 Status Report, if submitted. Loop ID 2310A Referring Provider Name P.257 NM1 P.260 REF Referring Provider Name - Refer to TR3 Referring Provider Secondary Identification - Refer to TR3 Loop ID 2310B Rendering Provider Name P.262 NM1 Rendering Provider Name - Refer to TR3 P.265 PRV PRV03 (Provider It is strongly encouraged to enter the Rendering Provider Reference Taxonomy taxonomy code to uniquely identify the Specialty Info Identification Code) provider. P.267 REF P.269 NM1 P.272 N3 Rendering Provider Secondary Identification - Refer to TR3 Service Facility Location Name - Refer to TR3 Service Facility Location Address - Refer to TR3 Loop ID 2310C Service Facility Location Name P.273 N4 P.275 REF P.277 PER Serv Fac Loc City, State, ZIP - Refer to TR3 Service Facility Secondary Identification - Refer to TR3 Service Facility Contact Information - Refer to TR3 *Although loops, segments and/or data elements required for Medicaid Reclamation are clarified in the definition and notes as, they are not exclusive to Medicaid Reclamation type of claims only. Page 17 of 20

18 837 Professional Health Care Claim TR3 Segment Reference Designator(s) Value Definitions and Notes Specific to Anthem Loop ID 2310D Supervising Provider Name P.280 NM1 P.283 REF Supervising Provider Name - Refer to TR3 Supervising Provider Secondary Identification - Refer to TR3 Loop ID 2310E Ambulance Pick-Up Location P.285 NM1 Ambulance Pick-up Location - Refer to TR3 P.287 N3 Ambulance Pick-up Location Address - Refer to TR3 P.288 N4 Ambulance Pick-up Location City, State, ZIP Code - Refer to TR3 Loop ID 2310F Ambulance Drop-Off Location P.290 NM1 Ambulance Drop-off Location - Refer to TR3 P.292 N3 Ambulance Drop-off Location Address - Refer to TR3 P.293 N4 Ambulance Drop-off Location City, State, ZIP Code - Refer to TR3 For COB claims, enter data elements in Loops 2320, 2330A, 2330B, and/or Loop ID 2320 Other Subscriber Information P.295 SBR Other Subscriber Information - Refer to TR3 P.299 CAS Claim Level Adjustments - Refer to TR3 P.305 AMT COB Payer Paid Amount - Refer to TR3 P.306 AMT AMT02 If populated, submit Explanation of Benefits to validate noncovered COB Total Non- Monetary Amount amount for Commercial COB claims (Loop 2300 PWK, Covered Amount 'EB'). P.307 AMT Remaining Patient Liability - Refer to TR3 P.308 OI Other Insurance Coverage Information - Refer to TR3 P.310 MOA Outpatient Adjudication Information - Refer to TR3 Loop ID 2330A Other Subscriber Name P.313 NM1 Other Subscriber Name - Refer to TR3 P.316 N3 Other Subscriber Address - Refer to TR3 P.317 N4 Other Subscriber City, State, ZIP Code - Refer to TR3 P.319 REF Other Subscriber Secondary Identification - Refer to TR3 Loop ID 2330B Other Payer Name Other Payer Name - Refer to TR3 Other Payer Address - Refer to TR3 P.320 NM1 P.322 N3 P.323 N4 P.325 DTP P.326 REF P.328 REF P.329 REF P.330 REF P.331 REF Other Payer City, State, ZIP Code - Refer to TR3 Claim Check or Remittance Date - Refer to TR3 Other Payer Secondary Identifier - Refer to TR3 Other Payer Prior Authorization Number - Refer to TR3 Other Payer Referral Number - Refer to TR3 Other Payer Claim Adjustment Indicator - Refer to TR3 Other Payer Claim Control Number - Refer to TR3 Loop ID 2330C Other Payer Referring Provider P.332 NM1 Other Payer Referring Provider - Refer to TR3 P.334 REF Other Payer Referring Provider Secondary Identification - Refer to TR3 Loop ID 2330D Other Payer Rendering Provider P.336 NM1 Other Payer Rendering Provider - Refer to TR3 P.338 REF Other Payer Rendering Provider Secondary Identification - Refer to TR3 Loop ID 2330E Other Payer Service Facility Location P.340 NM1 Other Payer Service Facility Location - Refer to TR3 P.342 REF Other Payer Service Facility Location Secondary Identification - Refer to TR3 Loop ID 2330F Other Payer Supervising Provider P.343 NM1 Other Payer Supervising Provider - Refer to TR3 P.345 REF Other Payer Supervising Provider Secondary Identification - Refer to TR3 Page 18 of 20

19 837 Professional Health Care Claim TR3 Segment Reference Designator(s) Value Definitions and Notes Specific to Anthem Loop ID 2330G Other Payer Billing Provider P.347 NM1 P.349 REF Other Payer Billing Provider - Refer to TR3 Other Payer Billing Provider Secondary Identification - Refer to TR3 Loop ID 2400 Service Line P.350 LX Service Line Number - Refer to TR3 P.351 SV1 SV Modifiers must be used to correctly identify anesthesia services. Professional Procedure Modifier Please refer to basic instructions. Service SV102 (Line Item Sum of service line charges must equal the Monetary Amount Charge Amt) Total Claim Charge Amount in 2300 CLM02. SV104 Conversion factor for anesthesia services: 15 min = 1 unit. Quantity Units truncated to whole integers during processing (ex processed as 15). P.359 SV5 Durable Medical Equipment Service - Refer to TR3 P.362 PWK Line Supplemental Information - Refer to TR3 P.366 PWK Durable Medical Equipment Certificate of Medical Necessity Indicator - Refer to TR3 P.368 CR1 Ambulance Transport Information - Refer to TR3 P.371 CR3 Durable Medical Equipment Certification - Refer to TR3 P.373 CRC Ambulance Certification - Refer to TR3 P.376 CRC Hospice Employee Indicator - Refer to TR3 P.378 CRC Condition Indicator/Durable Medical Equipment - Refer to TR3 P.380 DTP DTP03 (Service Date) Both "From Date" and "To Date" are required Date - Service Date Date Time Period when place of service is 22 or 23. P.382 DTP Date - Prescription Date - Refer to TR3 P.383 DTP Date - Certification Revision/Recertification Date - Refer to TR3 P.384 DTP Date - Begin Therapy Date - Refer to TR3 P.385 DTP Date - Last Certification Date - Refer to TR3 P.386 DTP P.387 DTP P.388 DTP P.389 DTP P.390 DTP P.391 QTY P.392 QTY P.393 MEA Date - Last Seen Date - Refer to TR3 Date - Test Date - Refer to TR3 Date - Shipped Date - Refer to TR3 Date - Last X-ray Date - Refer to TR3 Date - Initial Treatment Date - Refer to TR3 Ambulance Patient Count - Refer to TR3 Obstetric Anesthesia Additional Units - Refer to TR3 Test Result - Refer to TR3 P.395 CN1 Contract t Information - Refer to TR3 P.397 REF Repriced Line Item Reference Number - Refer to TR3 P.398 REF Adjusted Repriced Line Item Reference Number - Refer to TR3 P.399 REF Prior Authorization - Refer to TR3 P.401 REF Line Item Control Number - Refer to TR3 P.403 REF Mammography Certification Number - Refer to TR3 P.404 REF CLIA Number - Refer to TR3 P.405 REF Referring CLIA Facility Identification - Refer to TR3 P.406 REF Immunization Batch Number - Refer to TR3 P.407 REF Referral Number - Refer to TR3 P.409 AMT Service Tax Amount - Refer to TR3 P.410 AMT Postage Claimed Amount - Refer to TR3 P.411 K3 File Information - Refer to TR3 P.413 NTE NTE02 Notes beyond 80 bytes overflow to Loop 2300 NTE02. Also, Line Note Description field reserved for overflow from Loop 2300 NTE02. P.414 NTE Third Party Organization Notes - Refer to TR3 P.415 PS1 Purchased Service Information - Refer to TR3 P.416 HCP Line Pricing/Repricing Information - Refer to TR3 Page 19 of 20

20 TR3 Segment Reference Designator(s) Value Loop ID 2410 Drug Identification P.423 LIN Drug Identification LIN03 Product/Service ID (National Drug Code) P.426 CTP P.428 REF Drug Quantity - Refer to TR3 Prescription of Compound Drug Association Number - Refer to TR3 Loop ID 2420A Rendering Provider Name P.430 NM1 Rendering Provider Name - Refer to TR3 P.433 PRV PRV03 (Provider Rendering Provider Reference Taxonomy Specialty Info Identification Code) provider. P.434 REF Rendering Provider Secondary Identification - Refer to TR3 Loop ID 2420B Purchased Service Provider Name P.436 NM1 P.439 REF Purchased Service Provider Name - Refer to TR3 Purchased Service Provider Secondary Identification - Refer to TR3 Loop ID 2420C Service Facility Location Name P.441 NM1 P.444 N3 P.445 N4 P.447 REF Service Facility Location Name - Refer to TR3 Service Facility Location Address - Refer to TR3 Service Facility Location City, State, ZIP Code - Refer to TR3 Service Facility Location Secondary Identification - Refer to TR3 Loop ID 2420D Supervising Provider Name P.449 NM1 Supervising Provider Name - Refer to TR3 P.452 REF Supervising Provider Secondary Identification - Refer to TR3 Loop ID 2420E Ordering Provider Name P.454 NM1 Ordering Provider Name - Refer to TR3 P.457 N3 Ordering Provider Address - Refer to TR3 P.458 N4 Ordering Provider City, State, ZIP Code - Refer to TR3 P.460 REF Ordering Provider Secondary Identification - Refer to TR3 P.462 PER Ordering Provider Contact Information - Refer to TR3 Loop ID 2420F Referring Provider Name P.465 NM1 Referring Provider Name - Refer to TR3 P.468 REF Referring Provider Secondary Identification - Refer to TR3 Loop ID 2420G Ambulance Pick-Up Location P.470 NM1 Ambulance Pick-up Location - Refer to TR3 P.472 N3 Ambulance Pick-up Location Address - Refer to TR3 P.473 N4 Ambulance Pick-up Location City, State, ZIP Code - Refer to TR3 Loop ID 2420H Ambulance Drop-Off Location P.475 NM1 Ambulance Drop-off Location - Refer to TR3 P.477 N3 Ambulance Drop-off Location Address - Refer to TR3 P.478 N4 Ambulance Drop-off Location City, State, ZIP Code - Refer to TR3 Loop ID 2430 Line Adjudication Information P.480 SVD SVD02 (Service Line Line Adjudication Monetary Amount Paid Amount) Information P.484 CAS P.490 DTP P.491 AMT Line Adjustment - Refer to TR3 Line Check or Remittance Date - Refer to TR3 Remaining Patient Liability - Refer to TR3 Loop ID 2440 Form Identification Code P.492 LQ Form Identification Code - Refer to TR3 P.494 FRM Supporting Documentation - Refer to TR3 P.496 SE 837 Professional Health Care Claim Transaction Set Trailer - Refer to TR3 Definitions and Notes Specific to Anthem For Medicaid, submit the NDC # for prescribed drugs and biologics. It is strongly encouraged to enter the taxonomy code to uniquely identify the Enter the paid amount from the other carrier(s) Explanation of Benefits. *Although loops, segments and/or data elements required for Medicaid Reclamation are clarified in the definition and notes as, they are not exclusive to Medicaid Reclamation type of claims only. Page 20 of 20