The "Abridged" tab displays only those data elements pulled from PsychConsult for the 837 file submission.

Transcription

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

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

3 Description Table Column Header B.3 ISA01 Authorization Information HIPAA_ authorization_id_qualifier Global Subcode for 837 Header Information HIPAA Code R Category = 837 Header Information Global Code = ISA Segment 01 Global Subcode = Coverage Plan = Any value (cannot be empty) HIPAA Code = Select from drop-down 00 = auth info present This is the advised code to send unless security requirements mandate use of additional identification information. 03 = Additional Data identification B.3 ISA02 Authorization Information HIPAA_ authorization_id Global Subcode for 837 Header Information HIPAA Code R Category = 837 Header Information Global Code = ISA Segment 02 Global Subcode = Coverage Plan = Any value (cannot be empty) HIPAA Code = You must manually enter the value in the HIPAA Code field. The process will save up to ten characters, all of which will print to the 837 file. If you enter no HIPAA Code value, the process will print spaces to the 837 file. B.4 ISA03 Security Information HIPAA_ security_id_qualifier Global Subcode for 837 Header Information HIPAA Code R Category = 837 Header Information Global Code = ISA Segment 03 Global Subcode = Coverage Plan = Any value (cannot be empty) HIPAA Code = Select from drop-down. (You may enter values other than those 00 = security info present This is the advised code to send unless security requirements mandate use of password data. listed in the drop-down.) The process will save up to ten characters, but only the 01 = Password first two characters will print to the 837 file. B.4 ISA04 Security Information HIPAA_ security_id Global Subcode for 837 Header Information If the HIPAA Code column is not populated, the process will print spaces to the 837 file. HIPAA Code R Category = 837 Header Information Category = ISA Segment 04 Subcode = Coverage Plan = Any value (cannot be empty) HIPAA Code = You must manually enter the value into the HIPAA Code field. The process will save up to ten characters, all of which will print to the 837 file. If you enter no HIPAA Code value, the process will print spaces to the 837 file. B.4 ISA05 Interchange HIPAA_ interchange_sender_ qualifier Global Subcode for 837 Header Information HIPAA Code R 1. When ISA06 is not populated under the 837 Header Information category: Category = s Mapping Code = Submitter Subcode = "Type" value from the Coverage Plan Window = Any value (cannot be empty) 01 = Duns 14 = Duns Plus Suffix 20 = Health Industry Number 2. When ISA05 and ISA06 are populated under the 837 Header Information category: Category = 837 Header Information Code = ISA Segment 05 Subcode = Coverage Plan 3. When ISA06 is populated but ISA05 is not populated under the 837 Header Information category: The process populates as "ZZ" by default. 27 = Carrier Identification Number as assigned by HCFA 28 = Fiscal Intermediary Identification Number as assigned by HCFA 29 = Medicare Number as assigned by HCFA 30 = US Federal Tax Identification Number 33 = National Association of Insurance Commissioners Company Code ZZ = Mutually Defined

4 Description Table Column B.4 ISA06 Interchange Sender HIPAA_ interchange_sender_id Global Subcode for 837 Header Information HIPAA Code R You must manually enter the value into the HIPAA Code field. The process will save up to ten characters, all of which will print to the 837 file. If the HIPAA Code field is not populated, the process will populate with the value mapped in GS02 as follows: Global Subcode where: Category = s Mapping Code = Submitter Subcode = the Electronic s Type entered in the Coverage Plan window. B.4 ISA07 Interchange HIPAA_ interchange_receiver_ qualifier Global Subcode for 837 Header Information HIPAA Code R In order for ISA07 to print to the 837 file, the HIPAA Code column for ISA08 must be populated. If the ISA08 is not populated, the process will populate the ISA07 with the HIPAA Code from the Receiver Global Code in the s Mapping Category. 01 = Duns 14 = Duns Plus Suffix 20 = Health Industry Number If the HIPAA Code field for ISA08 is populated, but ISA07 is not, the process will print "ZZ" in the 837 file. 27 = Carrier Identification Number as assigned by HCFA 28 = Fiscal Intermediary Identification Number as assigned by HCFA 29 = Medicare Number as assigned by HCFA 30 = US Federal Tax Identification Number 33 = National Association of Insurance Commissioners Company Code B.5 ISA08 Interchange Receiver HIPAA_ interchange_receiver_id Global Subcode for 837 Header Information HIPAA Code R You must manually enter the value into the HIPAA Code field. The process will save up to ten characters, all of which will print to the 837 file. If the HIPAA Code field is not populated, the process will populate with the value mapped in GS03 as follows: Global Subcode where: Category = s Mapping Code = Submitter Subcode = the Electronic s Type entered in the Coverage Plan window. ZZ = Mutually Defined B.5 ISA09 Interchange Date Global Subcode for 837 Header Information R The process will populate with the date stamp on the file. B.5 ISA10 Interchange Time Global Subcode for 837 Header Information R The process will populate with the time stamp on the file. B.5 ISA11 Interchange Control Standards Identifier B.5 ISA12 Interchange Control Version Number B.5 ISA13 Interchange Control Number HIPAA_ HIPAA_ HIPAA_ interchange_control_ standards_id interchange_control_ version_no Global Subcode for 837 Header Information Global Subcode for 837 Header Information interchange_control_no_header Global Subcode for 837 Header Information R Always populated by the process as "U". U = U.S. EDI Community of ASC X12, TDCC, and UCS R R Always calculated and populated by the process. The Control Number is always populated by the process as "1" to match the number sent in IEA02 of the record.

5 Description Table Column B.6 ISA14 Acknowledgment Requested HIPAA_ B.6 ISA15 Usage Indicator HIPAA_ B.6 ISA16 Component Separator HIPAA_ B.8 GS01 Functional Identifier Code HIPAA_ B.8 GS02 Application Sender's Code HIPAA_ acknowledge_requested Global Subcode for 837 Header Information HIPAA Code R Select "0" or "1" from the drop-down. (You may enter values other than what is in the drop-down.) The process will save up to ten characters, but only the first character will print to the 837 file. If the HIPAA Code column is NOT populated, the process will populate as "1" by default. usage_indicator Configuration 837USAGE_IND RV Select the appropriate value from the drop-down depending on whether this is Production or Test data. component_separator Configuration 837SUBELEM_SEP R The delimiter used to separate component data elements is populated here by the process. 0 = Acknowledgment Requested 1 = Interchange Acknowledgement Requested P = Production Status functional_id_code R Always populated by the process as "HC". HC = Health Care (837) application_sender_code Global Subcode R Global Subcode where: Category = s Mapping, Global Code = Submitter, Global Subcode =the Electronic s Type entered in the Coverage Plan window. T = Test B.8 GS03 Application Receiver's Code HIPAA_ application_receiver_ code Global Subcode R Global Subcode where: Category = s Mapping, Global Code = Receiver, Global Subcode = the Electronic s Type entered in the Coverage Plan window. B.8 GS04 Date R The process will populate with the date stamp on the file. B.8 GS05 Time R The process will populate with the time stamp on the file. B.9 GS06 Group Control Number HIPAA_ group_control_no_header R The Control Number is always populated by the process with the Batch number which must match the number sent in GE02 of the record. B.9 GS07 Responsible Agency Code HIPAA_ responsible_agency_ code R Always populated by the process as "X". X = Accredited Standards Committee X12 B.9 GS08 Version/ Release/ Industry Identifier Code HIPAA_ version_code Configuration 837P_TRANS_ TYPE_CODE RV Always populated by the process as "004010X098DA1". 62 ST02 Transaction Set Control Number trans_set_control_no_ header N/A N/A R Populated by the process with a sequential number starting at " ". 64 BHT02 Transaction Set Purpose Code 64 BHT03 Originator Application Transaction Identifier 64 BHT04 Transaction Set Creation Date 65 BHT05 Transaction Set Creation Time Hard-coded by stored procedure Hard-coded by stored procedure trans_set_purpose_code N/A N/A R Always populated by the process as "00". 00 = Original appl_trans_id N/A N/A R Populated by the process with the date and time stamp from when the file was created. trans_creation_date N/A N/A R Populated by the process with the current date in the format "ccyymmdd". trans_creation_time N/A N/A R Populated by the process with the current time in the format "hhmmssdd".

6 Description Table Column 65 BHT06 or Encounter Identifier 66 REF02 Transmission Type Code Loop 1000A Submitter 68 NM102 Entity Type encounter_id N/A N/A R Always populated by the process as "CH". CH = Chargeable trans_type_code Configuration 837P_TRANS_ TYPE_CODE RV Always populated by the process with "004010X098A1" X098A1 = Production submitter_entity_qualifier N/A N/A R Always populated by the process as "2". 2 = n-person Entity 68 NM103 Submitter Last or Organization submitter_lname RV Populated by the process with the first 35 characters of the. 69 NM109 Submitter Identifier submitter_id Global Subcode / Coverage Plan Subcode / Electronic s Type RV Global Subcode where: Category = s Mapping, Global Code = Submitter, AND the Subcode matches the Electronic s Type entered in the Coverage Plan window. 72 PER02 Submitter Contact submitter_contact_name RV Populated by the process with the. 72 PER03 Communication Number submitter_comm_no_1_ qualifier Telephone R Populated by the process as "TE" where telephone type = Office (Global code OP). TE = Telephone 72 PER04 Communication Number submitter_comm_no_1 Telephone RV Populated by the process with the Telephone Number. 73 PER05 Communication Number submitter_comm_no_2_ qualifier Telephone Populated by the process as "FX" where telephone type = Fax (Global code BF). FX = Fax 73 PER06 Communication Number submitter_comm_no_2 Telephone Populated by the process with the Fax Number. Loop 1000B Receiver 75 NM103 Receiver receiver_lname Coverage Plan Plan RV Populated by the process with the first 35 characters of the Coverage Plan. 75 NM109 Receiver Primary Identifier receiver_primary_id Global Subcode / Coverage Plan Subcode / Electronic s Type RV Global Subcode where: Category = "s Mapping", Global Code = "Receiver ", AND the Subcode matches the Electronic s Type entered in the Coverage Plan window. Loop 2010AA Billing 85 NM102 Billing Entity Type billing_provider_type_ qualifier R Always populated by the process as "2". 2 = n-person Entity 85 NM103 Billing Last or Organizational billing_provider_lname, Clinic, or Protocol, Program,, Clinic, or RV Based on the CSPP level or where the Tax is located, the process populates with the first 30 characters of either Protocol, Program, s, Clinic, or.

7 Description Table Column 86 NM108 Identification Code 86 NM109 Billing Identifier billing_provider_id_ qualifier billing_provider_id, Clinic, Coverage Plan, or R "XX" or "24" Populated by the process using 'XX' if NPI exists. If no NPI exists, populates with the Tax qualifier. NPI or Tax RV Populated by the process with the NPI Number or Tax. Beginning with the lowest level on the CSPP, the process looks for the NPI on the detail window, working up from the Protocol level to the Clinic level until the NPI is found. XX = National 24 = Employer's Identification Number If not found, the process looks on the coverage plan window for the NPI associated with the specific coverage plan. If not found, the process looks for the NPI associated with the coverage plan "STANDARD". If the NPI is still not found, the process picks up the NPI from the window. te: If the NPI is still not found, the process is repeated in search of the Tax. 88 N301 Billing Address Line 1 billing_provider_addr_1, Clinic, or Address 1 RV Based on the CSPP level or where the Tax is located, the process selects the Billing Address (BI global code). If there is no Billing Address for the, the process selects the Address. 88 N302 Billing Address Line 2 billing_provider_addr_2, Clinic, or Address 2 Based on the CSPP level or where the Tax is located, the process selects the Billing Address (BI global code). If there is no Billing Address for the, the process selects the Address. 89 N401 Billing City billing_provider_city, Clinic, or City CV Based on the CSPP level or where the Tax is located, the process selects the Billing Address (BI global code). If there is no Billing Address for the, the process selects the Address. 90 N402 Billing State or Province Code billing_provider_state, Clinic, or State CV Based on the CSPP level or where the Tax is located, the process selects the Billing Address (BI global code). If there is no Billing Address for the, the process selects the Address. 90 N403 Billing Postal Zone or ZIP Code billing_provider_zip, Clinic, or Zip CV Based on the CSPP level or where the Tax is located, the process selects the Billing Address (BI global code). If there is no Billing Address for the, the process selects the Address.

8 Description Table Column 92 REF01 Reference Identification billing_provider_addtl_ qualifier Global Code HIPAA Code associated with Electronic s Type category If claim_oput_billing_secndry_id flag in the Coverage_Plan table is set to: N = Always populated with 'EI'. 0B = State License Number 1A = Blue Cross Number Y = First REF01 segment always populated with 'EI'; and a second REF01 segment is populated with the HIPAA Code associated with the following : 1B = Blue Shield Number Global Code Category = Electronic s Type Global Code = Coverage Plan 1C = Medicare Number 1D = Medicaid Number 1G = UPIN Number 1H = CHAMPUS Identification Number 1J = Facility Number B3 = Preferred Organization Number BQ = Health Maintenance Organization Code Number EI = Employer's Identification Number FH = Clinic Number G2 = Commercial Number G5 = Site Number LU = Location Number SY = Social Security Number The Social Security Number may not be used for Medicare U3 = Unique Supplier Identification Number (USIN) 92 REF02 Reference Identification billing_provider_addtl_id, Clinic Information, or Coverage Plan Tax and If claim_oput_billing_secndry_id flag in the Coverage_Plan table is set to: N = Always populated with Tax. Y = First REF02 segment always populated with Tax ; and a second REF02 segment populated with (if found) is also included. X5 St t I d t i l A id t P id 97 PER02 Billing Contact billing_provider_contact_name Used only if the address comes from the CSPP vs. from the. The value "Billing " will be printed by the process. 97 PER03 Communication Number billing_provider_comm_ no_1_qualifier CV The process will populate with the telephone number based on the CSPP level or where the Tax is located. If the telephone type = "BI" (Billing) or "OP" (Office), then populated by the process as "TE". TE = Telephone FX = Facsimile If the telephone type = "BF" (Fax), then populated by the process as "FX".

9 Description Table Column 97 PER04 Communication Number billing_provider_comm_ no_1, Clinic, or Telephone CV The process first looks for and populates with the Billing phone number, then the Office phone number, then the Fax number, dependent on the level where the Tax is stored. 98 PER05 Communication Number billing_provider_comm_ no_2_qualifier CV The process will populate with the telephone number based on the CSPP level or where the Tax is located. If the telephone type = "BI" (billing) or "OP" (office), then "TE". TE = Telephone FX = Facsimile If the telephone type = "BF" (fax), then "FX". 98 PER06 Communication Number billing_provider_comm_ no_2, Clinic, or Telephone CV The process will look for and populate with the first that is found of the Billing phone number, the Office phone number, or the Fax number, dependent on the level where the Tax is stored. Loop 2010AB Pay to 100 NM102 Entity Type pay_to_provider_type_ qualifier R Always populated by the process as "2". 2 = n-person Entity 100 NM103 Last or Organization pay_to_provider_lname, Clinic, or Protocol, Program,, Clinic, or RV Based on the CSPP level or where the Tax is located, the process populates with the first 30 characters of either the Protocol, Program,, Clinic, or. 101 NM108 Identification Code 101 NM109 Identification Code pay_to_provider_id_ qualifier pay_to_provider_id, Clinic, Coverage Plan, or R "XX" or "24" Populated by the process using 'XX' if NPI exists. If no NPI exists, populates with the Tax qualifier. NPI or Tax RV Populated by the process with the NPI Number or Tax. Beginning with the lowest level on the CSPP, the process looks for the NPI on the detail window, working up from the Protocol level to the Clinic level until the NPI is found. XX = National 24 = Employer's Identification Number If not found, the process looks on the coverage plan window for the NPI associated with the specific coverage plan. If not found, the process looks for the NPI associated with the coverage plan "STANDARD". If the NPI is still not found, the process picks up the NPI from the window. te: If the NPI is still not found, the process is repeated in search of the Tax. 103 N301 Pay-to Address 1 pay_to_provider_addr_1, Clinic, or Address 1 RV The process will select the 837 Pay To Address (H837PAYTO global code) from the. If no Pay To address exists, the process will print the Payment Address from the upper part of the window (above the Address field). 103 N302 Pay-to Address 2 pay_to_provider_addr_2, Clinic, or Address 2 The process will select the 837 Pay To Address (H837PAYTO global code) from the. If no Pay To address exists, the process will print the Payment Address from the upper part of the window (above the Address field).

10 Description Table Column 104 N401 Pay-to City pay_to_provider_city, Clinic, or City RV The process will select the 837 Pay To Address (H837PAYTO global code) from the. If no Pay To address exists, the process will print the Payment Address from the upper part of the window (above the Address field). 104 N402 Pay-to State pay_to_provider_state, Clinic, or State RV The process will select the 837 Pay To Address (H837PAYTO global code) from the. If no Pay To address exists, the process will print the Payment Address from the upper part of the window (above the Address field). 105 N403 Pay-to Zip Code pay_to_provider_zip, Clinic, or Zip RV The process will select the 837 Pay To Address (H837PAYTO global code) from the. If no Pay To address exists, the process will print the Payment Address from the upper part of the window (above the Address field). 106 REF01 Reference Identification pay_to_provider_sec_qualifier Coverage Plan, Global Code HIPAA Code associated with Electronic s Type If claim_oput_billing_secndry_id flag in the Coverage_Plan table is set to: N = Always populated with 'EI'. 0B = State License Number 1A = Blue Cross Number Y = First REF01 segment always populated with 'EI'; and a second REF01 segment is populated with the HIPAA Code associated with the following : 1B = Blue Shield Number Global Code Category = Electronic s Type Global Code = Coverage Plan 1C = Medicare Number 1D = Medicaid Number 1G = UPIN Number 1H = CHAMPUS Identification Number 1J = Facility Number B3 = Preferred Organization Number BQ = Health Maintenance Organization Code Number EI = Employer's Identification Number FH = Clinic Number G2 = Commercial Number G5 = Site Number LU = Location Number SY = Social Security Number The Social Security Number may not be used for Medicare U3 = Unique Supplier Identification Number (USIN) X5 St t I d t i l A id t P id

11 Description Table Column 107 REF02 Pay-to Additonal Identifier pay_to_provider_sec_id, Clinic Information or Coverage Plan If claim_oput_billing_secndry_id flag in the Coverage_Plan table is set to: N = Always populated with Tax. Y = First REF02 segment always populated with Tax ; and a second REF02 segment populated with (if found) is also included. Loop 2000B - Subscriber Hierarchical The Subscriber loop 2000B will repeat each time there is a new Insured andeach time within the Insured the changes. 109 HL04 Hierarchical Child Code hier_child_code RV If the insured is the patient, the process will populate with "0", otherwise will populate with "1". 0 = Self 1 = Other 110 SBR01 Payer Responsibility Sequence Number Code copay_priority Coverage Coverage Priority RV If the coverage priority = 1, the process will enter "P". If the coverage priority = 2, the process will enter "S". P = Primary S = Secondary If the coverage priority 3, the process will enter "T". T = Tertiary 111 SBR02 Relationship Code relation_code If the insured is the patient, the process will enter "18", otherwise the process will 18 = Self leave blank. 111 SBR03 Insured Group or Policy Number coverage_group_no Coverage Details Insured's Group or Policy Number If the group number on the coverage is blank, the policy number will be sent in this field by the process. If both are blank, nothing is sent in this field by the process. 111 SBR04 Insured Group coverage_plan_name Coverage Details Coverage Plan 111 SBR05 Insurance Type Code medicare_type_code Global Code for Type HIPAA Code The process will look up and populate with the payor type associated with the Coverage Plan and the HIPAA code associated with the applicable payor type. If Medicare is not the primary payor, the process will enter "47". 47 = Medicare Secondary, Other Liability Insurance is Primary

12 Description Table Column 113 SBR09 Filing Indicator Code claim_filing_ind Global Subcode for Type HIPAA Code RV The User must enter each coverage plan under the Global Subcode's payor type and map the coverage plan to the appropriate HIPAA Code. Category = Type Global Code = Coverage Plan Type Global Subcode = Coverage Plan If there is no HIPAA Code mapped to the coverage plan, the process will default as "ZZ". 09 = Self-pay 10 = Central Certification 11 = Other n-federal Programs 12 = Preferred Organization (PPO) 13 = Point of (POS) 14 = Exclusive Organization (EPO) 15 = Indemnity Insurance 16 = Health Maintenance Organization (HMO) Medicare Risk AM = Automobile Medical BL = Blue Cross/Blue Shield CH = Champus CI = Commercial Insurance Co. DS = Disability HM = Health Maintenance Organization LI = Liability LM = Liability Medical MB = Medicare Part B MC = Medicaide OF = Other Federal Program TV = Title V VA = Veteran Administration Plan WC = Workers' Compensation Health ZZ = Mutually Defined 115 PAT05 Date Time Period Format t displayed in the GUI; only in the table Always populated by the process as "D8". D8 = Date expressed in Format CCYYMMDD 115 PAT06 Insured Individual Death Date subscriber_date_of_ death Intake - Adm tab Date of Death Included by the process in the file if the patient is the insured and the date of death is populated, otherwise the process will leave blank. 116 PAT09 Pregnancy Indicator Loop 2010BA - Subscriber 118 NM102 Entity Type pregnancy_ind subscriber_entity_ qualifier t used in the "STANDARD". In most cases, this field is not being kept up to date so we are not using it in the standard implementation. R Always populated by the process as "1". 1 = n-person Entity 118 NM103 Subscriber Last 118 NM104 Subscriber First 118 NM105 Subscriber Middle 118 NM107 Subscriber Suffix subscriber_lname or Relationship Last RV If the patient is the insured, populated by the process with the patient last name; otherwise populated with the last name of the insured relationship. suscriber_fname or Relationship First If the patient is the insured, populated by the process with the patient first name; otherwise populated with the first name of the insured relationship. subscriber_mname or Relationship Middle If the patient is the insured, populated by the process with the patient middle name; otherwise populated with the middle name of the insured relationship. subscriber_suffix or Relationship Suffix If the patient is the insured, populated by the process with the patient suffix; otherwise populated with the suffix of the insured relationship.

13 Description Table Column 119 NM108 Identification Code 119 NM109 Subscriber Primary Identifier 121 N301 Subscriber Address Line N302 Subscriber Address Line 2 subscriber_id_qualifier Always populated by the process as "MI". MI = Member Identification Number subscriber_insured_id Coverage Details Insured's Number RV subscriber_addr_1 or Relationship Address 1 CV If the patient is the insured, populated by the process with the patient address; otherwise populated with the address of the insured relationship. subscriber_addr_2 or Relationship Address 2 If the patient is the insured, populated by the process with the patient address; otherwise populated with the address of the insured relationship. 122 N401 Subscriber City 123 N402 Subscriber State Code subscriber_city or Relationship City CV If the patient is the insured, populated by the process with the patient city; otherwise populated with the city of the insured relationship. subscriber_state or Relationship State CV If the patient is the insured, populated by the process with the patient state; otherwise populated with the state of the insured relationship. 123 N403 Subscriber Postal Zone or ZIP Code subscriber_zip or Relationship Zip CV If the patient is the insured, populated by the process with the patient zip; otherwise populated with the zip of the insured relationship. 123 N404 Subscriber Country Code subscriber_country_code t used in. 125 DMG02 Subscriber Birth Date 125 DMG03 Subscriber Gender Code subscriber_dob or Relationship Birthdate CV If the patient is the insured, populated by the process with the patient date of birth; otherwise populated with the date of birth of the insured relationship. subscriber_sex or Relationship Sex CV If the patient is the insured, the process will look up and populate with the HIPAA code associated with the patient sex; otherwise populated with the sex of the insured relationship. The process will default to "U" if this information is not available. Loop 2010BB - Payer 131 NM103 Payer payor_name Coverage Details Coverage Plan RV Populated by the process with the first 35 characters of coverage plan name. 131 NM108 Identification Code payor_id_qualifier R Always populated by the process as "PI". PI = Identification

14 Description Table Column 131 NM109 Payer Identifier elec_claims_payor_id Protocol Information, Program Information, Information, Clinic Information, or Coverage Plan window EMC, RV The process will look to the EMC for the applicable coverage. If EMC is not found, based on the CSPP level where the Tax is located, the process will look to the Information window for that level for the specific coverage plan or an ALL row (coverage plan of "STANDARD"). If not found at any level of the CSPP, the process will look in the Coverage Plan window for the. The process will flag as an error if not found. 134 N301 Payer Address Line 1 payor_addr_1 Coverage Plan Corporate Address 1 The process will look at the patient's coverage for claim address. If not present, the process will look for the claim address on the Coverage window. If not present, the process will use the Corporate address on the Coverage Plan window. 134 N302 Payer Address Line N401 Payer City 136 N402 Payer State Code payor_addr_2 Coverage Plan Corporate Address 2 payor_city Coverage Plan Corporate Address City payor_state Coverage Plan Corporate Address State 136 N403 Payer Postal Zone or ZIP Code payor_zip Coverage Plan Corporate Address Zip 136 N404 Payer Country Code Loop 2010BC - Responsible Party payor_country_code t used in. 140 NM102 Entity Type responsible_qualifier Always populated by the process as "1". 1 = Person 140 NM103 Responsible Party Last or Organization 140 NM104 Responsible Party First 141 NM105 Responsible Party Middle responsible_lname Relation Last CV If the patient is not financially responsible, the process will populate with the relationship who is marked as financially responsible for the patient. responsible_fname Relation First If the patient is not financially responsible, the process will populate with the relationship who is marked as financially responsible for the patient. responsible_mname Relation Middle If the patient is not financially responsible, the process will populate with the relationship who is marked as financially responsible for the patient. 141 NM106 Prefix t used in.

15 Description Table Column 141 NM107 Responsible Party Suffix 143 N301 Responsible Party Address Line N302 Responsible Party Address Line N401 Responsible Party City 144 N402 Responsible Party State Code 145 N403 Responsible Party Postal Zone or ZIP Code responsible_suffix Relation Suffix If the patient is not financially responsible, the process will populate with the relationship who is marked as financially responsible for the patient. responsible_addr_1 Relation Address 1 CV If the patient is not financially responsible, the process will populate with the relationship who is marked as financially responsible for the patient. responsible_addr_2 Relation Address 2 If the patient is not financially responsible, the process will populate with the relationship who is marked as financially responsible for the patient, if used. responsible_city Relation City CV If the patient is not financially responsible, the process will populate with the relationship who is marked as financially responsible for the patient. responsible_state Relation State CV If the patient is not financially responsible, the process will populate with the relationship who is marked as financially responsible for the patient. responsible_zip Relation Zip CV If the patient is not financially responsible, the process will populate with the relationship who is marked as financially responsible for the patient. 145 N404 Responsible Party Country Code respsonsible_country_ code t used in. Loop 2000C - Hierarchical Level 154 PAT01 Relationship to Insured patient_relationship Relation Relation (Relation Type global Code) CV If the patient is not the insured and the Relation Type is mapped to a HIPAA Code, the HIPAA Code is used by the process. If the Relation Type is not mapped to a HIPAA Code, the process populates by default to "G8". G8 = Other Relationship 155 PAT05 Death Date patient_date_of_death Intake - Pat Administration tab Date of Death Included by the process in the file if the patient is the insured and date of death is populated; otherwise the process will leave blank. 156 PAT09 Pregnancy Indicator patient_pregnancy_ind t used in the "STANDARD". In most cases, this field is not being kept up to date so we are not using in the standard implementation. Loop 2010CA NM103 Last 158 NM104 First 158 NM105 Middle 158 NM107 Suffix patient_lname Last CV If the patient is not the insured, the process will populate with the patient last name. patient_fname First CV If the patient is not the insured, the process will populate with the patient first name. patient_mname Middle If the patient is not the insured, the process will populate with the patient middle name. patient_suffix Suffix If the patient is not the insured, the process will populate with the patient suffix.

16 Description Table Column 161 N301 Address Line N302 Address Line N401 City 162 N402 State Code patient_addr_1 Address 1 CV If the patient is not the insured, the process will populate with the patient address 1. patient_addr_2 Address 2 If the patient is not the insured, the process will populate with the patient address 2, if used. patient_city City CV If the patient is not the insured, the process will populate with the patient City. patient_state State CV If the patient is not the insured, the process will populate with the patient State. 163 N403 Postal Zone or ZIP Code patient_zip Zip CV If the patient is not the insured, the process will populate with the patient Zip. 163 N404 Country Code patient_country_code t used in. 165 DMG02 Birth Date 165 DMG03 Gender Code patient_dob Date of Birth CV If the patient is not the insured, the process will populate with the patient date of birth. patient_sex Sex CV If the patient is not the insured, the process will look up the HIPAA code associated with the sex of the patient. The process will populate by default to "U" if the information is not available. U = Unknown Loop Information 171 CLM01 Account Number - foreign key _ Transaction claim_id, s Submission + R Populated by the process with + (from the Transaction table). 172 CLM02 Total Charge Amount total_amt Fee Matrix Charge Amount, Disallowance, Max Print Amount CV Populated by the process with the sum of one of the following for all transactions included in the file: If Print Amt Type = "Net", the Charge Amount less Disallowance. If Print Amt Type = "Charges", the Charge Amount. The total Charge Amount will not exceed the Max Print Amount. 173 CLM05-1 Facility Type Code place_of_service Place of R If the Place of is blank, the process will populate as "99". 99 = Other Unlisted Facility 173 CLM05-3 Submission Reason Code submission_reason_code RV Always populated by the process as "1". Corrected, Replacement, and Void claim reason codes will not be sent at this time. 1 = Original 174 CLM06 or Supplier Signature Indicator signature_ind R Always populated by the process as "Y". Y = Yes

17 Description Table Column 174 CLM07 Medicare Assignment Code medicare_assign_code Coverage Plan Accept Assignment RV If Accept Assignment = "Y" in the Coverage Plan window, the process will populate as "A". If Accept Assignment "Y" in the Coverage Plan window, the process will populate as "P". A = Assigned P = Refuses to Assign Benefits 175 CLM08 Benefits Assignment Certification Indicator benefits_assign_cert_ind Coverage Details Accept Assignment RV If Accept Assignment = "Y" in the Coverage Details window, then "Y". If Accept Assignment "Y" in the Coverage Details window, then "N". Y = Yes N = 175 CLM09 Release of Information Code 176 CLM10 Signature Source Code release_code Coverage Details Accept Assignment RV Always populated by the process as "Y". Y = Yes, has a signed statement permitting release of medical billing data related to a claim patient_signature_code Coverage Details Accept Assignment R Always populated by the process as "B". B = Signed signature authorization form or forms for both HCFA-1500 Form block 12 and block 13 are on file 176 CLM11-1 Related Causes Code 176 CLM11-2 Related Causes Code 176 CLM11-3 Related Causes Code related_causes_1_code related_causes_2_code related_causes_3_code t reported. does not store the accident date which is required if this field is reported. t reported. does not store the accident date which is required if this field is reported. t reported. does not store the accident date which is required if this field is reported. 177 CLM11-4 Auto Accident State or Province Code auto_accident_state_ code t reported. does not store the accident state which is required if this field is reported. 178 CLM11-5 Country Code country_code t reported. does not store the accident country which is required if this field is reported. 184 DTP03 Referral Date referral_date Assignment or Referred Date, Requested Date, Scheduled Date, Enrolled Date, or Episode Open Date Referral information is not sent at the claim level, only at the service level. 209 DTP03 Related Hospitalization Admission Date related_hosp_admin_ date Assignment or Enrolled Date, Episode Open Date If the Place of is "21", "34", "51", "52", "55", or "56", and this is an Inpatient transaction, the process will use the earliest Enrolled Date of one of the assignments on the claim. 21 = Inpatient Hospital 34 = Hospice If there are no patient assignments, the process will use the Episode Open Date on the patient record. 51 = Inpatient Psychiatric Facility If this is an Outpatient transaction, this segment will not be sent. 52 = Psychiatric Facility - Partial Hospitalization 55 = Residential Substance Abuse Treatment Facility 56 = Psychiatric Residential Treatment Center

18 Description Table Column 211 DTP03 Related Hospitalization Discharge Date related_hosp_discharge_date Assignment or Discharge Date, Episode Close Date If the Place of is "21", "34", "51", "52", "55", or "56", and this is an Inpatient transaction, the process will use the earliest Discharged Date of the assignments included on the claim. 21 = Inpatient Hospital 34 = Hospice If there are no patient assignments, the process will use the Episode Close Date on the patient record. 51 = Inpatient Psychiatric Facility If this is an Outpatient transaction, this segment will not be sent. 52 = Psychiatric Facility - Partial Hospitalization 55 = Residential Substance Abuse Treatment Facility 215 PWK01 Report Type Code attachment_rpt_type_code R Code indicating the title or contents of a document, report, or supporting item. Pre-populated by stored procedures - proc.pcsp_h837pi_note and procpcsp_h837pi_pwk - where the document code from the list is entered. 56 = Psychiatric Residential Treatment Center 77 = Support Data for Verification Referral. Use this code to indicate a completed referral form. AS = Admission Summary B2 = Prescription B3 = Physician Order B4 = Referral Form CT = Certification DA = Dental Models DG = Diagnostic Report DS = Discharge Summary EB = Explanation of Benefits (Coordination of Benefits or Medicare Secondary ) MT = Models NN = Nursing tes OB = Operative te OZ = Support Data for PN = Physical Therapy Certification PO = Prosthetics or Orthotic Certification PZ = Physical Therapy Certification RB = Radiology Films RR = Radiology Reports RT = Report of Tests and Analysis Report

19 Description Table Column 216 PWK02 Report Transmission Code attachment_transmission_code Code defining timing, transmission method, or format by which reports are to be sent. Pre-populated by a stored procedure where the document availability code from the list is entered. AA = Available on Request at Site This means that the paperwork is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM = By Mail EL = Electronically Only Use to indicate that attachment is being transmitted in a separate X12 functional group. EM = FX = By Fax 216 PWK05 Identification Code attachment_qualifier Code designating the process \ method of code structure used for identification code (67). AC = Attachment Control Number te: Required if PWK02 = "BM", "EL", "EM", or "FX". 216 PWK06 Identification Code attachment_control_no Code identifying a party or other code. te: Required if PWK02 = "BM", "EL", "EM", or "FX". 220 AMT01 Amount Code CV If a patient has made a payment for any services on this claim, this segment the process will send populated with "F5". This works off of a stored procedure in the HIPAA engine. F5 = Amount Paid 220 AMT02 Paid Amount patient_amt_paid Payment Payment Amount CV If a patient has made a payment for any services on this claim, this segment will be sent by the process. 228 REF01 Reference Identification prior_authorization_no_ qualifier If the clinical transaction references an authorization, the process will populate as "G1"; otherwise the process will leave blank. G1 = Prior Authorization Number 228 REF02 Prior Authorization Number prior_authorization_no Procedure Authorization Auth. (for patient) 230 REF02 Original Reference Number orig_reference_no t used in. 241 REF02 Medical Record Number 247 NTE01 te Reference Code 247 NTE02 Description medical_record_no MRN note_ref_code note_text Code identifying the functional area or purpose for which the note applies. ADD = Additional Information Pre-populated by a stored procedure where the functional area code from the list CER = Certification Narrative is entered. DCP = Goals, Rehabilitation Potential, or Discharge Plans Pre-populated by a stored procedure where the functional area description is entered. DGN = Diagnosis Description PMT = Payment TPO = Third Party Organization tes

20 Description Table Column 266 H101 Diagnosis Code diagnosis_1_code Clinical Transaction Axis I & II (Billing Dx) RV This is the Principal diagnosis. The diagnosis code in the first position on the clinical transaction with the latest procedure date is assumed to be Principal. 266 H102 Diagnosis Code diagnosis_2_code Clinical Transaction Axis I & II (Billing Dx) Populated by the process with all DX codes listed in the clinical transactions included in this claim, other than the Principal DX included in H H103 Diagnosis Code diagnosis_3_code Clinical Transaction Axis I & II (Billing Dx) Populated by the process with all DX codes listed in the clinical transactions included in this claim, other than the Principal DX included in H H104 Diagnosis Code diagnosis_4_code Clinical Transaction Axis I & II (Billing Dx) Populated by the process with all DX codes listed in the clinical transactions included in this claim, other than the Principal DX included in H H105 Diagnosis Code diagnosis_5_code Clinical Transaction Axis I & II (Billing Dx) Populated by the process with all DX codes listed in the clinical transactions included in this claim, other than the Principal DX included in H H106 Diagnosis Code diagnosis_6_code Clinical Transaction Axis I & II (Billing Dx) Populated by the process with all DX codes listed in the clinical transactions included in this claim, other than the Principal DX included in H H107 Diagnosis Code diagnosis_7_code Clinical Transaction Axis I & II (Billing Dx) Populated by the process with all DX codes listed in the clinical transactions included in this claim, other than the Principal DX included in H H108 Diagnosis Code diagnosis_8_code Clinical Transaction Axis I & II (Billing Dx) Populated by the process with all DX codes listed in the clinical transactions included in this claim, other than the Principal DX included in H101. te: Referring information was previously reported only at the service level. It is now reported at the claim level. However, if a single service has a different referring provider than other services, the referring information will be sent at both the claim level and the service level. Loop 2310A - Referring 283 NM101 Entity Identifier Code 283 NM102 Entity Type referring_entity_code Clinical Transaction If referring staff is on the clinical transaction, the process will populate as "DN"; otherwise the process will leave blank. referring_entity_qualifier Clinical Transaction If referring staff is on the clinical transaction, the process will populate as "1"; otherwise the process will leave blank. DN = Referring 1 = Person 283 NM103 Referring Last referring_lname Clinical Transaction Referring MD CV If referring staff is on the clinical transaction, the process will populate with Last ; otherwise the process will leave blank. 283 NM104 Referring First referring_fname Clinical Transaction Referring MD If referring staff is on the clinical transaction, the process will populate with First ; otherwise the process will leave blank. 284 NM105 Referring Middle referring_mname Clinical Transaction Referring MD If referring staff is on the clinical transaction, then Middle ; otherwise leave blank. 284 NM108 Identification Code referring_id_qualifier "XX" or "24" Populated by the process using 'XX' if NPI exists. If no NPI exists, populates with the Tax qualifier. XX = National 24 = Employer's Identification Number

21 Description Table Column 284 NM109 Referring Identifier referring_id, Clinic, or Tax Populated by the process with the NPI Number or Tax. Beginning with the lowest level on the CSPP, the process looks for the NPI on the detail window, working up from the Protocol level to the Clinic level until the NPI is found. If not found, the process looks on the coverage plan window for the NPI associated with the specific coverage plan. If not found, the process looks for the NPI associated with the coverage plan "STANDARD". If the NPI is still not found, the process picks up the NPI from the window. te: If the NPI is still not found, the process is repeated in search of the Tax. 286 PRV03 Referring Taxonomy Code referring_taxonomy_code Staff Taxonomy This is no longer a required field per the 837 addenda, but will be sent by the process if populated. 288 REF01 Referring Secondary referring_secondary_ qualifier If the staff_secondary_id column in the Coverage_Plan table is set to 'Y', this column is populated with qualifier for the, UPIN, or SSN. If none of these is found, the column is not populated. 1B = Blue Shield 1C = Medicare If the staff_secondary_id column in the Coverage_Plan table is set to 'N', this column is not populated 1D = Medicaid te: This column is not populated if the NPI is not used. 1G = Upin Number 1H = CHAMPUS Number G2 = Commercial Number SY = Social Security Number 289 REF02 Referring Secondary referring_secondary_id Information for Staff or Staff, UPIN, or SSN If the staff_secondary_id_column in the Coverage Plan table is set to 'Y', this column is populated in the following manner: The process will first look for and populate with the. If not found, the process will look for and populate with the UPIN. If not found, the process will look for and populate with the staff social security number. If none of the three are found, this element will not be sent by the process. If the staff_secondary_id_column in the Coverage_Plan table is set to 'N', This column is not populated. Loop 2310B - Rendering 291 NM102 Entity Type rendering_entity_qualifier CV Always populated by the process as "1". 1 = Person 291 NM103 Rendering Last 291 NM104 Rendering First rendering_lname Clinical Transaction Billing Clinician Last Populated by the process with the last name of the billing clinician on the clinical transaction. rendering_fname Clinical Transaction Billing Clinician First Populated by the process with the first name of the billing clinician on the clinical transaction.

22 Description Table Column 292 NM105 Rendering Middle rendering_mname Clinical Transaction Billing Clinician Middle Populated by the process with the middle name of the billing clinician on the clinical transaction. 292 NM108 Identification Code 292 NM109 Rendering Identifier rendering_id_qualifier CV "XX" or "24" rendering_id, Clinic, or Populated by the process using 'XX' if NPI exists. If no NPI exists, populates with the Tax qualifier. Tax CV Populated by the process with the NPI Number or Tax. Beginning with the lowest level on the CSPP, the process looks for the NPI on the detail window, working up from the Protocol level to the Clinic level until the NPI is found. XX = National 24 = Employer's Identification Number If not found, the process looks on the coverage plan window for the NPI associated with the specific coverage plan. If not found, the process looks for the NPI associated with the coverage plan "STANDARD". If the NPI is still not found, the process picks up the NPI from the window. te: If the NPI is still not found, the process is repeated in search of the Tax. 294 PRV03 Taxonomy Code rendering_taxonomy_ code Staff Taxonomy This is no longer a required field per the 837 addenda, but will be sent by the process if populated. 296 REF01 Rendering Identification rendering_secondary_qualifer Information for Staff HIPAA Secondary CV If the staff_secondary_id column in the Coverage_Plan table is set to 'Y', this column is populated with qualifier for the, UPIN, or SSN. If none of these is found, the column is not populated. 1B = Blue Shield 1C = Medicare If the staff_secondary_id column in the Coverage_Plan table is set to 'N', this column is not populated 1D = Medicaid te: This column is not populated if the NPI is not used. 1G = Upin Number 1H = CHAMPUS Number G2 = Commercial Number SY = Social Security Number 297 REF02 Rendering Secondary Identifier rendering_secondary_id Information for Staff or Staff, UPIN, or SSN If the staff_secondary_id_column in the Coverage Plan table is set to 'Y', this column is populated in the following manner: The process will first look for and populate with the. If not found, the process will look for and populate with the UPIN. If not found, the process will look for and populate with the staff social security number. If none of the three are found, this element will not be sent by the process. If the staff_secondary_id_column in the Coverage_Plan table is set to 'N', This column is not populated. Loop 2310D - Facility Location 304 NM101 Entity Identifier Code facility_entity_code R Always populated by the process as "77". 77 = Location