837 Institutional Health Care Claim Outbound. Section 1 837I Institutional Health Care Claim: Basic Instructions

Transcription

1 Companion Document 837I 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 837I Institutional Health Care Claim: Basic Instructions Section 2 837I Institutional Health Care Claim: Enveloping Section 3 837I Institutional Health Care Claim: Charts for Situational Rules Any questions? Contact MCS/JAA representatives dl-mcsit@anthem.com Contact EDI Solutions Desk 1 (800) edi-ca@anthem.com LiveChat Page 1 of 11

2 Section 1 - Basic Instructions 1.1 X12 and HIPAA Compliance Checking, and Business Edits EDI interchanges submitted from Anthem Blue Cross (Anthem) for processing pass through compliance edits. In response to the outbound , trading partners must return a 999 in the submitter s trading partner mailbox for acknowledgment. 1.2 HIPAA Compliant Codes HIPAA-compliant codes will be used 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-9-CM) Diseases National Uniform Billing Committee (NUBC) Codes Diagnosis Related Group Number (DRG) Provider Taxonomy Codes National Drug Code *ICD-10 codes are not allowed prior to effective mandate date of October 1, Diagnosis Codes According to the 837I TR3, a transaction is not X12 compliant if decimal points are used in diagnosis codes. Therefore, Anthem will not send diagnosis codes containing a decimal point. 1.4 Uppercase Letters, Special Characters, and Delimiters As specified in the TR3, the basic character set includes uppercase letters, digits, space, and other special characters. All alpha characters will be submitted in UPPERCASE letters only. To avoid syntax errors, hyphens, parentheses and spaces are not used in values for identifiers. Examples: Zip Code Medical Record # Anthem will not use the following special characters: asterisk (*), less than/greater than signs (<, >), colon (:), and slash (/). This minimizes the risk for a special character to be recognized as a delimiter. Example: 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 incorrectly be identified as 12 and Decimal R Data Elements R data elements are those that contain a decimal point; involving monetary amounts, units, visits, weights, and frequency. Anthem will use decimal points for monetary amounts, and whole numbers for other types of R data elements. 1.6 Numeric s, Monetary Amounts and Units Anthem pays all claims in US dollars and therefore, accepts monetary amounts in US dollars only. Codes related to foreign currencies will not be used. No negative service line charge or negative units will be used in SVC segment. SV203 Monetary Amount - Line Item Charge Amount SV205 Quantity - Service Unit Count Page 2 of 11

3 Section 2 - 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 Institutional Health Care Claim Envelope Specific from Anthem Blue Cross (TR3, Appendix C) ISA Interchange Control Header GS Functional Group Header GE Functional Group Trailer IEA Interchange Control Trailer ISA01 00 GS01 HC GE01 refer to TR3 IEA01 refer to TR3 ISA02 10 spaces GS02 PRBCCA GE02 refer to TR3 IEA02 refer to TR3 ISA03 00 PSBCCA ISA04 10 spaces GS03 RECEIVER ID ISA05 ZZ GS04 refer to TR3 ISA06 PRBCCA GS05 refer to TR3 PSBCCA GS06 refer to TR3 ISA07 ZZ GS07 X ISA08 RECEIVER ID GS08 ISA09 refer to TR3 ISA10 refer to TR3 ISA11 ^ (5E) ISA ISA13 refer to TR3 ISA14 refer to TR3 *ISA06/GS02=PRBCCA represents JAA ISA15 refer to TR3 *ISA06/GS02=PSBCCA represents PRICE ONLY/FFE ISA16 refer to TR3 Page 3 of 11

4 Section 3 - Charts for Situational Rules Listed below are loops, segments, and data elements required for proper adjudication by Anthem per the situational rules in the 837I TR3. TR3 Segment Reference P.67 ST Transaction Set Header ST03 Implementation Convention Ref P.68 BHT BHT06 CH Beginning of Transaction Type Hierarchical Trx Code Loop ID 1000A Submitter Name P.71 NM1 NM103 WGS20 Submitter Name Last Name or Organization Name (Submitter Identification Code Identifier) P.73 PER PER02 PROGRAMMER Submitter EDI Name ON CALL Contact Information PER03 TE Comm No.Qualifier PER Comm Number Loop ID 1000B Receiver Name P.76 NM1 NM103 (Receiver Receiver Name Last Name or Name) Organization Name Identification Code Loop ID 2000A Billing Provider Hierarchical Level P.78 HL Billing Provider Hierarchical Level - Refer to TR3 P.80 PRV PRV01 BI Billing Provider Provider Code Specialty PRV03 (Provider Information Ref Identification Taxonomy Code) Loop ID 2010AA Billing Provider Name P.84 NM1 NM Billing Provider Entity ID Code Name (Billing Prov Identification Code Identifier) P.87 N3 Billing Provider Address - Refer to TR3 P.88 N4 N403 (Billing Billing Provider Postal Code Provider's Zip City, State, ZIP Code) P.90 REF Billing Provider Tax Identification - Refer to TR3 P.91 PER PER02 (Billing Prov Billing Provider Contact Information Name PER03 Comm No.Qualifier PER04 Comm Number Contact Name) TE (Comm. Number) - Health Care Claim, Institutional CH - Chargeable Represents Anthem Blue Cross as submitter. Identifies ETIN established by Trading Partner Agreement. Submitter Contact Name TE - Telephone Communication Number Represents Name of MCS Client. Represents the Receiver Primary Identification Number. BI - Billing Taxonomy code that applies to the service Billing Provider NPI ('XX') for Non-Exempt providers Billing Provider Zip Code will be used as the practicing zip code. Contact Name for Billing Provider TE - Telephone Phone Number for Billing Provider Contact Page 4 of 11

5 Loop ID 2000B Subscriber Hierarchical Level P.107 HL Subscriber Hierarchical Level - Refer to TR3 P.109 SBR Subscriber SBR01 Payer Resp P, S, T Usage of 'S' or 'T' accompanies information populated in Loop 2320 and 2330 for COB Information Seq No. Code adjudication information. SBR03 (Group Anthem Blue Cross assigned number Group Number Number) Format 10 position alphanumeric Loop ID 2010BA Subscriber Name P.112 NM1 NM Individual Subscriber Name Entity Type Qual. NM108 MI MI - Member Identification Number ID Code Qualifier Subscriber ID bytes Identification Code Recommended to have software support 20 bytes. P.115 N3 Subscriber Address - Refer to TR3 P.116 N4 Subscriber City, State, ZIP Code - Refer to TR3 P.118 DMG Subscriber Demographic Information - Refer to TR3 P.120 REF Subscriber Secondary Identification - Refer to TR3 P.121 REF Property and Casualty Claim Number - Refer to TR3 Loop ID 2010BB Payer Name P.122 NM1 NM103 WGS20 Represents Anthem Blue Cross as payer. Payer Name Payer Name NM108 PI PI - Payer Identification ID Code Qualifier (Payer Primary represents Anthem Blue Cross Identification Code Identifier) P.124 N3 Payer Address - Refer to TR3 P.125 N4 Payer City, State, ZIP Code - Refer to TR3 P.127 REF Payer Secondary Identification - Refer to TR3 P.129 REF Billing Provider Secondary Identification - Refer to TR3 Loop ID 2000C Patient Hierarchical Level P.131 HL Patient Hierarchical Level - Refer to TR3 Loop ID 2300 Claim Information P.143 CLM CLM01 (Patient Control Maximum of 20 alphanumeric characters. Claim Information Clm Submitter's ID Number) CLM02 (Total Claim equals the total amount of submitted Monetary Amount Charge Amt) charges for service lines in Loop 2400 SV203. P.149 DTP Discharge Hour - Refer to TR3 P.150 DTP DTP03 (Statement Valid medical codes will be based on the Statement Dates Date Time Period From / To Date) "Statement From Date" P.151 DTP DTP Admission i Admission Date/Time Qualifier Date/Hour DTP03 (Admission Date and Hour) Date/Time Period P.152 DTP P.153 CL1 P.154 PWK Date-Repricer Received Date - Refer to TR3 Institutional Claim Code - Refer to TR3 Claim Supplemental Information - Refer to TR3 P.158 CN1 Contract Information - Refer to TR3 P.160 AMT Patient Estimated Amount Due - Refer to TR3 P.161 REF Service Authorization Exception Code - Refer to TR3 Page 5 of 11

6 Loop ID 2300 Claim Information (cont'd) P.163 REF Referral Number - Refer to TR3 P.164 REF REF01 Prior Authorization Ref ID Qualifier REF02 Ref Identification P.166 REF REF01 Payer Claim Ref ID Qualifier Control Number REF02 P.167 REF P.168 REF P.169 REF REF G1 (Prior Auth Number) F8 (Payer Claim Ref Identification Control No.) Repriced Claim Number - Refer to TR3 Adjusted Repriced Claim Number - Refer to TR3 G1 - Prior Authorization Number Investigational Device Exemption Number - Refer to TR3 P.170 REF01 D9 D9 - Claim Number Claim ID for Ref ID Qualifier Transmission Intermediaries REF02 Ref Identification (VAN Trace No.) For Entertainment Guilds, this represents the HIN Network Referral Number. F8 - Original Reference Number Represents the claim number assigned by Anthem Blue Cross. Represents Anthem s Document Claim Number (DCN). P.172 REF Auto Accident State - Refer to TR3 P.173 REF Medical Record REF01 Ref ID Qualifier EA EA - Medical Record Identification Number Number REF02 Ref Identification (Medical Record Number) P.174 REF P.175 REF P.176 K3 Demonstration Project Identifier - Refer to TR3 PRO Approval Number - Refer to TR3 File Information - Refer to TR3 NTE Segment applies to BlueCard MCS/JAA ONLY P.178 NTE Claim Note NTE01 Note Ref Code ADD Additional Information NTE02 Claim Note Text Provides the Secondary Payer Pricing Qualifier (SPPQ), Medicare Payer Pricing Qualifier Code (MPPQ), HOST/HOME status (TPA), Claim Receipt Date, and 835 File Response Indicator. Bytes 1-19: SPPQ information, if applicable DISCOUNT VALID ITS-HOST-PAYS-PRVDR 835=Y~ DISCOUNT NOT VALID ITS-HOST-PAYS-PRVDR 835=Y~ DISCNT CONDITIOINAL ITS-HOST-PAYS-PRVDR 835=Y~ Byte 20: MPPQ information MEDICARE PAYER PRICING QUALIFIER CODE - ASSIGNED 1-Lines w/ Med Allowed Amt, Prov accepts Med Allowed Amt Lines w/o Med Allowed Amt, Prov accepts Host Allowed Amt 2-Lines w/ Med Allowed Amt, Prov accepts Med Allowed Amt Lines w/o Med Allowed Amt, Prov accepts the Charge Amt 3-Lines w/ Med Allowed Amt, Prov accepts lesser of Host or Med Allowed Amt Lines w/o Med Allowed Amt, Prov accepts Host Allowed Amt 4-Lines w/ Med Allowed Amt, Prov accepts lesser of Host or Med Allowed Amt Lines w/o Med Allowed Amt, Prov accepts the Charge Amt ITS-HOST-PAYS-PRVDR 835=Y~ ITS-HOST-PAYS-PRVDR 835=Y~ ITS-HOST-PAYS-PRVDR 835=Y~ ITS-HOST-PAYS-PRVDR 835=Y~ Page 6 of 11

7 Loop ID 2300 Claim Information (cont'd) NTE Segment applies to BlueCard MCS/JAA ONLY P.178 NTE Bytes 21-28: Date Claim Received Claim Note ITS-HOST-PAYS-PRVDR 835=Y~ Bytes 29-46: Pay to Subscriber/Provider, HOME represents you, the client ITS-HOST-PAYS-SUB 835=Y~ ITS-HOST-PAYS-PRVDR 835=Y~ For claims that require payment to the subscriber, Anthem will price the claim and forward to the client to handle direct. Payment must be handled by the client to the subscriber directly. Bytes 50-54: Yes/No indicator if 835 response required for PAR and ECRP ITS-HOST-PAYS-PRVDR 835=Y~ For CO, NV, and CA claims under Bluecard or JAA process, all the claims must be paid by Anthem. This means that all par and non-par providers will require an 835 back to Anthem to issue payment to providers directly. Bytes 56-57: CA Indicator for CA claim under JAA Process ONLY ITS-HOST-PAYS-PRVDR 835=Y CA~ P.180 NTE Billing Note - Refer to TR3 P.181 CRC EPSDT Referral - Refer to TR3 ICD-10 Codes are effective beginning October 1, ICD-9-CM Guide requires diagnosis codes to the highest level of specificity. Code is invalid if it has not been coded to the full number of digits required for that code. P.184 HI Principal Procedure Information - Refer to TR3 P.187 HI Admitting Diagnosis - Refer to TR3 P.189 HI Patient's Reason for Visit - Refer to TR3 P.193 HI External Cause of Injury - Refer to TR3 P.218 HI DRG Information - Refer to TR3 P.220 HI Other Diagnosis Information - Refer to TR3 P.239 HI Principal Procedure Information - Refer to TR3 P.242 HI Other Procedure Information - Refer to TR3 P.258 HI Occurrence Span Information - Refer to TR3 P.271 HI Occurrence Information - Refer to TR3 P.284 HI Information - Refer to TR3 P.294 HI Condition Information - Refer to TR3 P.304 HI Treatment Code Information - Refer to TR3 P.313 HCP Claim Pricing/ Repricing Information HCP01 Pricing Methodology HCP03 Monetary Amount HCP12 Quantity HCP13 Reject Reas Code Loop ID 2310A Attending Physician Name P.319 NM1 NM101 Attending Provider Entity ID Code Name Identification Code 00 - NON-PAR providers 01 - PAR provider with No allowable-full Discount 10 - Other Pricing (PAR Provider priced) 14 - Adjustment Pricing (except BlueCard and JAA/IntraPlan) Represents savings amount to consider on a claim level. Represents the approved service units or inpatient days. T1 71 (Rendering Primary ID) T1 - Cannot identify Provider as TPO (Third Party Organization) Participant 71 - Attending Provider NPI ('XX') for Non-Exempt providers Page 7 of 11

8 Loop ID 2310A Attending Physician Name (cont'd) P.322 PRV Attending Phys Specialty Info PRV03 Reference Identification (Provider Taxonomy Code) P.324 REF Attending Provider Secondary Identification - Refer to TR3 Enter the taxonomy code to uniquely identify the provider. Loop ID 2310B Operating Physician Name P.326 NM1 P.329 REF Operating Physician Name - Refer to TR3 Operating Physician Secondary Identification - Refer to TR3 Loop ID 2310C Other Operating Physician Name P.331 NM1 P.334 REF Other Operating Physician Name - Refer to TR3 Other Operating Physician Secondary Identification - Refer to TR3 Loop ID 2310D Rendering Provider Name P.336 NM1 Rendering Provider Name - Refer to TR3 P.339 REF Rendering Provider Secondary Identfication - Refer to TR3 Loop ID 2310E Service Facility Location Name P.341 NM1 NM Service Location Service Facility Entity ID Code Location Name (Service Fac NPI ('XX') for Non-Exempt providers Identification Code Loc Primary ID) P.344 N3 Service Facility Location Address - Refer to TR3 P.345 N4 Serv Fac Loc City, State, ZIP - Refer to TR3 P.347 REF REF01 0B 0B - Provider State License Number Service Facility Ref ID Qualifier Location REF02 (Service Facility Location Additional ID) Secondary Ref Identification Loop ID 2310F Referring Provider Name P.349 NM1 Referring Provider Name - Refer to TR3 P.352 REF Referring Provider Secondary Identification - Refer to TR3 Anthem will forward COB information (excluding Other Payer Address Information) whenever received from submitting provider/source. If data received is incomplete, dummy membership information will be populated solely for the purpose of passing COB amounts to the client. Loop ID 2320 Other Subscriber Information SBR segment created in support of SVD codes due to clinical editing / pricing even with no COB. P.354 SBR SBR01 P - Primary; S - Secondary; T - Tertiary Other Subscriber Payer Resp Information Sequence No. In support of SVD codes due to clinical editing or pricing, the Code value will match the payer resp seq code in Loop 2000B SBR01. SBR02 21 In support of SVC and CAS segments due to Individual Rel Code clinical editing or pricing, 21 will be used SBR09 CI In support of SVC and CAS segments due to Claim Filing clinical editing or pricing, CI will be used Indicator Code P.358 CAS Claim Level Adjustments - Refer to TR3 P.364 AMT AMT01 D D - Payer Paid Amount COB Payer Paid Amount Qualifier Amount Code AMT02 (Payer Paid Represents total amount paid by Other Payer. Monetary Amount Amount) P.365 AMT Remaining Patient Liability - Refer to TR3 P.366 AMT COB Total Non-Covered Amount - Refer to TR3 Page 8 of 11

9 TR3 Segment Reference Anthem will forward COB information (excluding Other Payer Address Information) whenever received from submitting provider/source. If data received is incomplete, dummy membership information will be populated solely for the purpose of passing COB amounts to the client. Loop ID 2320 Other Subscriber Information (cont'd) P.367 OI OI03 Represents assignment of benefits indicator. N - No; Y - Yes Oth Insurance Coverage Information Yes/No Condition or Response Code OI06 Release of Information Code In support of SVC and CAS segments due to clinical editing or pricing, Y will be used. Y - Yes, Provider has signed statement permitting release of medical billing data related to a claim P.369 MIA Inpatient Adjudication Information - Refer to TR3 P.374 MOA Outpatient Adjudication Information - Refer to TR3 Loop ID 2330A Other Subscriber Name P.377 NM1 NM103 Information from other carrier will be passed (exception: in Other Subscriber Name Last or support of SVC & CAS segments due to clinical editing or Name Organization Name pricing, REQ FOR ANTHEM SVD will be used). NM108 MI - Member Identification No.; ZZ - Mutually Defined ID Code Qualifier Identification Code Information from other carrier will be passed (exception: in support of SVC & CAS segments due to clinical editing or pricing, MI will be used). Information from other carrier will be passed (exception: in support of SVC & CAS segments due to clinical editing or pricing, 00 will be used). P.380 N3 P.381 N4 P.383 REF Other Subscriber Address - Refer to TR3 Other Subscriber City, State, ZIP Code - Refer to TR3 Other Subscriber Secondary Identification - Refer to TR3 Loop ID 2330B Other Payer Name P.384 NM1 P.386 N3 P.387 N4 Other Payer Name - Refer to TR3 Other Payer Address - Refer to TR3 Other Payer City, State, ZIP Code - Refer to TR3 P.389 DTP Claim Check or DTP01 Date/Time Qualifier Date Claim Paid Remittance Date DTP03 Date Time Period (Adjud. or Payment Date) Represents date the primary payer adjudicated the claim. P.390 REF P.392 REF P.393 REF Other Payer Secondary Identifier - Refer to TR3 Other Payer Prior Authorization Number - Refer to TR3 Other Payer Referral Number - Refer to TR3 P.394 REF Other Payer Claim Adjustment Indicator - Refer to TR3 P.395 REF Other Payer Claim Control Number - Refer to TR3 Loop ID 2330C Other Payer Attending Provider P.396 NM1 Other Payer Attending Provider - Refer to TR3 P.398 REF Other Payer Attending Provider Secondary Identification - Refer to TR3 Loop ID 2330D Other Payer Operating Physician P.400 NM1 Other Payer Operating Physician - Refer to TR3 P.402 REF Other Payer Operating Physician Secondary Identification - Refer to TR3 Page 9 of 11

10 Loop ID 2330E Other Payer Other Operating Physician P.404 NM1 Other Payer Other Operating Physician - Refer to TR3 P.406 REF Other Payer Other Operating Physician Secondary Identification - Refer to TR3 Loop ID 2330F Other Payer Service Facility Location o P.408 NM1 P.410 REF Other Payer Service Facility Location - Refer to TR3 Other Payer Service Facility Location Secondary Identification - Refer to TR3 Loop ID 2330G Other Payer Rendering Provider Name P.412 NM1 P.414 REF Other Payer Rendering Provider Name - Refer to TR3 Other Payer Rendering Provider Secondary Identfication - Refer to TR3 Loop ID 2330H Other Payer Referring Provider P.416 NM1 P.418 REF Other Payer Referring Provider - Refer to TR3 Other Payer Referring Provider Secondary Identification - Refer to TR3 Loop ID 2330I Other Payer Billing Provider P.420 NM1 P.422 REF Other Payer Billing Provider - Refer to TR3 Other Payer Billing Provider Secondary Identification - Refer to TR3 Loop ID 2400 Service Line Number P.423 LX Service Line Number - Refer to TR3 P.424 SV2 SV202-1 HC HC - Health Care Financing Administration Institutional Service Product/Service ID Qualifier Common Procedural Coding System (HCPCS) Codes SV203 Monetary Amount (Line Item Charge Sum of service line charges must equal the Total Claim Charge Amount in Loop 2300 CLM02. Amount) P.429 PWK Line Supplemental Information - Refer to TR3 P.433 DTP Service Date DTP03 Date Time Period (Service Date) P.435 REF REF02 (Line Item Control Number) Line Item Control Reference Number Identification P.437 REF Repriced Line Item Reference Number - Refer to TR3 P.438 REF Adjusted Repriced Line Item Reference Number - Refer to TR3 P.439 AMT Service Tax Amount - Refer to TR3 P.440 AMT Facility Tax Amount - Refer to TR3 P.441 NTE Third Party Organization Notes - Refer to TR3 P.442 HCP Service lines with HCP segment e are required ed to be returned ed on 835. Claim Pricing/ HCP NON-PAR providers Repricing Pricing 01 - PAR provider with No allowable-full Discount Information Methodology 10 - Other Pricing (PAR Provider priced) 14 - Adjustment Pricing (except BlueCard and JAA/IntraPlan) HCP03 Represents savings amount to consider on a detail line. Monetary Amount HCP12 Represents the approved service units or inpatient days. Quantity HCP13 T1 T1 - Cannot identify Provider as TPO (Third Reject Reas Code Party Organization) Participant Loop ID 2410 Drug Identification P.449 LIN Drug Identification - Refer to TR3 P.452 CTP Drug Quantity - Refer to TR3 P.454 REF Prescription of Compound Drug Association Number - Refer to TR3 Loop ID 2420A Operating Physician Name P.456 NM1 Operating Physician i Name - Refer to TR3 P.459 REF Operating Physician Secondary Identification - Refer to TR3 Page 10 of 11

11 Loop ID 2420B Other Operating Physician Name P.461 NM1 Other Operating Physician Name - Refer to TR3 P.464 REF Other Operating Physician Secondary Identification - Refer to TR3 Loop ID 2420C Rendering Provider Name P.466 NM1 Rendering Provider Name - Refer to TR3 P.469 REF Rendering Provider Secondary Identfication - Refer to TR3 Loop ID 2420D Referring Provider Name P.471 NM1 Referring Provider Name - Refer to TR3 P.474 REF Referring Provider Secondary Identification - Refer to TR3 Loop ID 2430 Line Adjudication Information Multiple Adjustments will be sent as they apply on COB claims. It will also be used to notify the receiver of denials or limitations found by our editing or pricing. P.476 SVD SVD01 (Other Payer Matches Loop 2330B identifying Line Adjudication Identification Code Primary Other Payer. Information SVD02 (Service Line Amount paid for this service line by Monetary Amount Paid Amount) COB/Medicare prior payer. SVD06 (Line Number) Bundled Line Number (will Be used ONLY for Assigned Number Claims Xten) P.480 CAS CAS01 CAS02 Line Adjustment Adj Group Code Adj Reason Code Anthem Adjustments made by Anthem PI COB DEDUCTIBLE AMOUNT PR 1 COINSURANCE AMOUNT PR 2 COPAYMENT AMOUNT PR 3 NON-ELIGIBLE AMOUNT CO 96 P.486 DTP P.487 AMT DISCOUNT AMOUNT CONTRACT EXCLUSION + CONTRACT LIMITATION Medicare DEDUCTIBLE AMOUNT Part A/B COINSURANCE AMOUNT COPAYMENT AMOUNT NON-ELIGIBLE AMOUNT CONTRACT EXCLUSION Line Check or Remittance Date - Refer to TR3 Remaining Patient Liability - Refer to TR3 P.488 SE Transaction Set Trailer - Refer to TR3 CO 45 OA 96 PR 1 PR 2 PR 3 CO 45 OA 96 Page 11 of 11