837 Encounter Companion Guide to the HIPAA Implementation Guide. Professional, Institutional, and Dental Claims

Transcription

1 837 Encounter Companion Guide to the HIPAA Implementation Guide Professional, Institutional, and Dental Claims June 2015 Minnesota Health Care Programs (MHCP) Provider Helpdesk

2 EDI Mapping Specifications - Introduction Page 2 of 85 CHANGE CONTROL Project or Date of Reason for change change 9/19/2013 TPL Requirements Transacti on 837D 837I 837P Loop/Segment/Data Element Data Element Name Value What was the change? L2300/AMT L2300/AMT02 Patient Estimated Amount Due Monetary Amount Removed description Removed description 837D L2320 Other Subscriber Information Added 2320 loop 837I 837P 837I 837P 837D 837I 837P 837D 837I 837P 837D 837I 837P 837D 837I 837P 837D 837I L2320 L2320/SBR01 L2320/SBR02 L2320/SBR03 L2320/SBR04 L2320/SBR09 L2320/SBR01 L2320/SBR02 L2320/SBR03 L2320/SBR05 L2320/SBR09 Other Subscriber Information Payer Responsibility Sequence Nbr Code Individual Relationship Code Reference Identification Name Claim Filing Indicator Code Payer Responsibility Sequence Nbr Code Individual Relationship Code Reference Identification Insurance Type Code Claim Filing Indicator Code See X12 IG for addt'l codes/values See X12 IG for addt'l codes/values Description identifies loop is required and MCO adjudication information as a payer is submitted here. Description refers user to X12 Implementation Guide for additional codes/values. Added SBR03 data element Added SBR04 data element Description added Description refers user to X12 Implementation Guide for additional codes/values. Description added Description added Description added L2320/CAS Claim Level Adjustments Added CAS segment L2320/AMT L2320/AMT01 L2320/AMT02 L2320/AMT L2320/AMT01 L2320/AMT02 L2320/AMT L2320/AMT01 L2320/AMT02 COB Payer Paid Amount Amount Qualifier Code Monetary Amount Remaining Patient Liability Amount Qualifier Code Monetary Amount COB Total Non-Covered Amount Amount Qualifier Code Monetary Amount D EAF A8 Added AMT segment Added AMT segment Added AMT segment L2330A Other Subscriber Name Added 2330A loop 2

3 EDI Mapping Specifications - Introduction Page 3 of 85 Date of change Project or Reason for change Transacti on 837D 837I 837P 837D 837I 837P Loop/Segment/Data Element Data Element Name Value What was the change? L2330A L2330A/NM102 L2330A/NM104 L2330A/NM105 L2330A/NM107 Other Subscriber Name Entity Type Qualifier Name First Name Middle Name Suffix Description identifies loop is required and MCO adjudication information as a payer is submitted here. 1 Added value: 1 - Person 837D L2330B Other Payer Name Added 2330B loop 837I 837P 837I 837P 837D 837I 837P 837D 837I 837P 837I 837P L2330B L2330B/NM109 Other Payer Name Identification Code Description identifies loop is required and MCO adjudication information as a payer is submitted here. Revised description no longer limits use to DHS MCO assigned UMPI. L2330B/DTP Claim Check or Remittance Date Added DTP segment L2330B/REF L2430 Other Payer Claim Control Number Line Adjudication Information Added REF segment, required for Medicare claims. 837D L2430 Line Adjudication Information Added 2430 loop 837I 837P 837I 837P 837I 837P L2430/SVD01 Identification Code Description identifies loop is required and MCO adjudication information as a payer is submitted here. Revised description no longer limits use to DHS MCO assigned UMPI. L2430/CAS Line Adjustment Added CAS segment L2430/AMT Remaining Patient Liability Added AMT segment 9/19/2013 Corrections 837P L2010AA/REF REF Billing Provider Tax Identification Corrected Requirement to "" 3

4 EDI Mapping Specifications - Introduction Page 4 of 85 Date of change Project or Reason for change Transacti on 837P 837P 837P Loop/Segment/Data Element Data Element Name Value What was the change? L2000B/SBR02 L2000B/SBR09 L2010BA/NM1 L2010BA/NM104 L2010BA/N402 L2010BA/N403 Individual Relationship Code Claim Filing Indicator Code Subscriber Name Name First State or Province Code Postal Code 18 MC Corrected Requirement to "" Corrected Requirement to "" Added Requirement of "" Corrected Requirement to "C2" Corrected Requirement to "C2" Corrected Requirement to "C2" 837P L2010BA/DMG Subscriber Demographics Corrected Requirement to "C2" 837I 837I L2300/HI01 L2300/HI02 thru HI12 L2300/HI02-1 thru HI12-1 L2300/HI02-2 thru HI12-2 L2300/HI01 L2300/HI02 thru HI12 L2300/HI02-1 thru HI103-1 L2300/HI02-2 thru HI103-2 L2300/HI02-9 thru HI103-9 Patient Reason for Visit Code Information Patient Reason for Visi Code Information Code List Qualifier Code Industry Code External Cause of Injury Code Information External Cause of Injury Code Information Code List Qualifier Code Industry Code Present on Admission Indicator APR/PR APR/PR ABN/BN ABN/BN Corrected Data Element to HI01 from HI01 thru HI12 Added data element with Requirement of "" Added data element component Added data element component Corrected Data Element to HI01 from HI01 thru HI12 Added data element with Requirement of "" Added data element component Added data element component Added data element component ABF/BF Corrected Data Element to HI01 L2300/HI01 Other Diagnosis Code Information ABF/BF from HI01 thru HI12 L2300/HI02 thru HI12 Other Diagnosis Code Information Added data element with 837I L2300/HI02-1 thru HI12-1 Code List Qualifier Code Requirement of "" L2300/HI02-2 thru HI12-2 Industry Code Added data element component L2300/HI02-9 thru HI12-9 Present on Admission Indicator Added data element component Added data element component BBQ/BQ Corrected Data Element to HI01 L2300/HI01 Principal Procedure Code Information BBQ/BQ from HI01 thru HI12 L2300/HI02 thru HI12 Other Procedure Code Information Added data element with 837I L2300/HI02-1 thru HI12-1 Code List Qualifier Code Requirement of "" L2300/HI02-2 thru HI12-2 Industry Code Added data element component L2300/HI02-3 thru HI12-3 Date Time Period Format Qualifier Added data element component L2300/HI02-4 thru HI12-4 Date Time Period Added data element component Added data element component 4

5 EDI Mapping Specifications - Introduction Page 5 of 85 Date of change Project or Reason for change Transacti on Loop/Segment/Data Element Data Element Name Value What was the change? BI Corrected Data Element to HI01 L2300/HI01 Occurrence Span Code Information BI from HI01 thru HI12 L2300/HI02 thru HI12 Occurrence Span Code Information Added data element with 837I L2300/HI02-1 thru HI12-1 Code List Qualifier Code Requirement of "" L2300/HI02-2 thru HI12-2 Industry Code Added data element component L2300/HI02-3 thru HI12-3 Date Time Period Format Qualifier Added data element component L2300/HI02-4 thru HI12-4 Date Time Period Added data element component Added data element component BH Corrected Data Element to HI01 L2300/HI01 Occurrence Code Information BH from HI01 thru HI12 Added L2300/HI02 thru HI12 Occurrence Code Information data element with Requirement of 837I L2300/HI02-1 thru HI12-1 Code List Qualifier Code "" Added data L2300/HI02-2 thru HI12-2 Industry Code element component L2300/HI02-3 thru HI12-3 Date Time Period Format Qualifier Added data element component L2300/HI02-4 thru HI12-4 Date Time Period Added data element component Added data element component BE Corrected Data Element to HI01 L2300/HI01 Value Code Information BE from HI01 thru HI12 L2300/HI02 thru HI12 Value Code Information Added data element with 837I L2300/HI02-1 thru HI12-1 Code List Qualifier Code Requirement of "" L2300/HI02-2 thru HI12-2 Industry Code Added data element component L2300/HI02-5 thru HI12-5 Monetary Amount Added data element component Added data element component BG Corrected Data Element to HI01 L2300/HI01 Condition Code Information BG from HI01 thru HI12 837I L2300/HI02 thru HI12 Condition Code Information Added data element with L2300/HI02-1 thru HI12-1 Code List Qualifier Code Requirement of "" L2300/HI02-2 thru HI12-2 Industry Code Added data element component Added data element component L2300/HI01 Principal Diagnosis Code Information ABF/BF Corrected Data Element to HI01 L2300/HI02 thru HI12 Diagnosis Code Information ABF/BF from HI01 thru HI12 837P L2300/HI02-1 thru HI12-1 Code List Qualifier Code Added line with Requirement of L2300/HI02-2 thru HI12-2 Industry Code "" Added data element component Added data element component 837I L2320/SBR L2320/SBR09 Other Subscriber Information Claim Filing Indicator Corrected Requirement to "" Corrected Requirement to "" 837I L2400/DTP Service Date Corrected Requirement to "" 5

6 EDI Mapping Specifications - Introduction Page 6 of 85 Date of change Project or Reason for change Transacti on 837I 837D 837I 837P 9/25/2013 MCO Paid Date 837D 11/4/2013 Taxonomy Code 11/4/2013 Service Facility 11/25/ /20/2013 HMS Implementation 837D 837I 837P 837D 837P Loop/Segment/Data Element Data Element Name Value What was the change? L2410/CTP03 Drug Quantity Unit Price Deleted data element. Not used per the X12 guide. L2430 Line Check or Remittance Date Corrected Data Element Name Corrected Requirement to "" L2400/DTP01 L2400/DTP02 L2400/DTP03 L2000A/PRV L2000A/PRV01 L2000A/PRV02 L2000A/PRV03 L2010AA/NM102 L2010AA/NM104 Paid Date Qualifier Date Format Qualifier MCO Paid Date Billing Provider Specialty Information Billing Provider Code Provider Taxonomy Code Qualifier Provider Taxonomy Code Billing Provider Entity Type Qualifier Billing Provider First Name 446 D8. BI PXC. 573 D8. Added DTP segment Added PRV segment 1 Added Value 1 - Person Added NM104 data element 837I L2010AA/NM103 Name Last or Organization Name Removed default instructions 837I 837P 837D 837I 837P 837D L2010AA/N301 L2010AA/N302 L2010AA/N401 L2010AA/N402 L2010AA/N403 Billing Provider Address Address Information City Name State or Province Code Postal Code Removed default instructions Added N302 data element Removed default instructions Corrected Requirement to "" Corrected Requirement to "" 837P L2010AA/REF Billing Provider Tax Identification Corrected Requirement to "" 837D 837P L2310C Service Facility Location Name Added Loop 2310C 837I L2310E Service Facility Location Name Added Loop 2310E 837D 837I 837P 837D 837I 837P L2330B/DTP01 L2330B/DTP02 L2330B/DTP03 L2000B/SBR01 Date Claim Paid Qualifier Date Format Qualifier Payment Date Payer Responsibility Sequence Nbr Code U Added DTP segment for Other Payer Claim Check or Remittance Date Added Value "U - Unknown"; deleted Values "P", "S" and "T". 12/4/2014 Denied Encounter Claims L2320/CAS04/CAS07/CAS10/CAS13/CAS1 6/CAS19 Quantity 6

7 EDI Mapping Specifications - Introduction Page 7 of 85 Date of change Project or Reason for change Transacti on 837D 837I 837P 837D 837I 837P Loop/Segment/Data Element Data Element Name Value What was the change? L2430/CAS04/CAS07/CAS10/CAS13/CAS1 6/CAS19 Quantity Revised description to include value to enter if claim denied at header level. Revised description to include value to enter if claim denied at service line level. 3/15/2015 T-MSIS Project 837D L2310A Referring Provider Name Added Loop 2310A 837D L2420C Supervising Provider Name Added Loop L2420C 837P L2420D Supervising Provider Name Added Loop L2420D 837P L2420E Ordering Provider Name Added Loop L2420E 837P L2420F Referring Provider Name Added Loop L2420E 837P L2310D Supervising Provider Name Added Loop L2310D 837I L2420D Referring Provider Name Added Loop L2310D 6/30/2015 MCO Received Date 837D 837I 837P L2300/DTP(050) 6/30/2015 Tracking ICN 837I L2300/NTE(ADD) Billing Note 6/30/2015 Tracking ICN 837D 837P L2300/NTE(ADD) Date - Repricer Received Date Claim Note 6/30/2015 Correction 837P L2400/K3 File Information Added segment L2300/DTP(050)01 MCO Received Date is submitted in this segment Added segment L2300/NTE for corrected ICN Added segment L2300/NTE for corrected ICN Used for submitting tooth number. Removed from L2300 and added to L

8 837 Encounter Companion Guide to the HIPAA Implementation Guide Table of Contents Introduction Professional Claims Envelope Information Institutional Claims Envelope Information Dental Claims Envelope Information Appendix Page 9 Page 10 Page 32 Page 34 Page 60 Page 62 Page 83 Page 85 8

9 837 Encounter Companion Guide to the HIPAA Implementation Guide 1 INTRODUCTION 1.1 Document Purpose Managed Care Organizations (MCOs) contracting with the (DHS) to provide prepaid health care services are required to provide encounter data in HIPAA compliant format. This companion guide further specifies the requirements to be used when preparing and submitting encounter data. Disclaimer The companion guide supplements, but does not contradict, disagree, oppose, or otherwise modify the HIPAA Implementation Guide in a manner that will make its implementation by users to be out of compliance. 1.2 Column Notations Req d: Required elements may be marked as: Required () Not required (N) Conditional according to the 837 HIPAA implementation guide () Conditional according to DHS additional requirements (C2) Value: If a value is present in the DHS Requirements Value Column the values MUST be entered. If no value is present refer to the Descriptions column for instructions. Description Column: This column will describe the value in the value column or give instructions for what must be submitted in the value column. 9

10 2 PROFESSIONAL LOOP HDR 837P HIPAA Implementation Guide Data SEG MENT NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION HEADER ST TRANSACTION SET HEADER ST01 TRANSACTION SET IDENTIFIER 837 HEALTH CARE CLAIM ST02 TRANSACTION SET CONTROL MCO SSTEM GENERATED NUMBER NUMBER ST03 IMPLEMENTATION CONVENTION REFERENCE BHT BEGIN OF HIERARCHICAL TXN BHT01 HIERARCHICAL STRUCTURE X222 A1 MUST BE SAME AS GS SOURCE, SUBSCRIBER, DEPENDENT BHT02 TRANSACTION SET PURPOSE 00 ORIGINAL 18 REISSUE BHT03 REFERENCE IDENTIFICATION SUBMISSION NUMBER-MCO ASSIGNED BHT04 DATE TRANSACTION SET CREATION DATE BHT05 TIME TRANSACTION SET CREATION TIME BHT06 TRANSACTION TPE RP REPORTING 1000A SUBMITTER NAME THIS LOOP IS USED FOR REGARDING THE MCO RESPONSIBLE FOR THE ENCOUNTER. NM1 SUBMITTER NAME NM101 ENTIT IDENTIFIER 41 VALUE 41 SHOULD BE SUBMITTED EVEN THOUGH THIS IS MCO. NM102 ENTIT TPE 2 NON-PERSON ENTIT PER SUBMITTER EDI CONTACT INFO NM103 NAME LAST OR ORGANIZATION MCO NAME (OR CONTRACTOR NAME) NAME NM108 IDENTIFICATION 46 TRADING PARTNER ID NM109 IDENTIFICATION MCO UMPI NUMBER ASSIGNED B DHS PER01 CONTACT FUNCTION IC CONTACT PER02 NAME MCO SUBMITTER CONTACT 10

11 837P HIPAA Implementation Guide Data LOOP SEG NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION MENT PER03 COMMUNICATION NUMBER TE TELEPHONE PER04 COMMUNICATION NUMBER MCO CONTACT PHONE NUMBER 1000B RECEIVER NAME NM1 RECEIVER NAME NM101 ENTIT IDENTIFICAT 40 RECEIVER NM102 ENTIT TPE 2 NON-PERSON ENTIT NM103 NAME LAST OR ORGANIZATION MN DEPT OF HUMAN SERVICES NAME NM108 IDENTIFICATION 46 TRADING PARTNER ID NM109 IDENTIFICATION RECEIVER ID 2000A BILLING/PA-TO PROVIDER HIERARCHICAL LEVEL HL HIERARCHICAL LEVEL HL01 HIERARCHICAL ID NUMBER 1 THEN INCREMENT B 1 HL03 HIERARCHICAL LEVEL 20 SOURCE HL04 HIERARCHICAL CHILD 1 ADDITIONAL SUBORDINATE HL DATA SEGMENT IN THIS HIERARCHICAL STRUCTURE PRV BILLING PROVIDER SPECIALT PRV01 PROVIDER BI BILLING PRV02 REFERENCE IDENTIFICATION PXC HEALTH CARE PROVIDER TAXONOM PRV03 REFERENCE IDENTIFICATION PROVIDER TAXONOM 2010AA BILLING PROVIDER NAME NM1 BILLING PROVIDER NAME NM101 ENTIT IDENTIFIER 85 BILLING PROVIDER NM102 ENTIT TPE 1 2 NM103 NAME LAST OR ORGANIZATION NAME PERSON NON-PERSON ENTIT STANDARD BILLING PROVIDER LAST OR ORGANIZATIONAL NAME NM104 NAME FIRST BILLING PROVIDER FIRST NAME NM108 IDENTIFICATION XX NPI NM109 IDENTIFICATION BILLING N3 BILLING PROVIDER ADDRESS N301 ADDRESS BILLING PROVIDER ADDRESS LINE N302 ADDRESS BILLING PROVIDER ADDRESS LINE 11

12 LOOP SEG MENT N4 REF 837P HIPAA Implementation Guide Data BILLING PROVIDER CIT/STATE/ZIP BILLING PROVIDER TAX IDENTIFICATION NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION N401 CIT NAME BILLING PROVIDER CIT NAME N402 STATE OR PROVINCE BILLING PROVIDER STATE OR PROVINCE N403 POSTAL BILLING PROVIDER POSTAL ZONE OR ZIP (9 DIGIT) REF01 REFERENCE IDENTIFICATION EI PROVIDERS EMPLOER IDENTIFICATION NUMBER 2000B REF02 BILLING PROVIDER TAX IDENTIFICATION NUMBER PROVIDERS EMPLOERS IDENTIFICATION NUMBER OR DEFAULT TO AN NUMBER NEEDED FOR STANDARD SUBSCRIBER HIERARCHICAL LEVEL HL HIERARCHICAL LEVEL HL01 HIERARCHICAL ID NUMBER START WITH 2 AND INCREMENT B 1. HL02 HIERARCHICAL PARENT ID 1 FOR FIRST ITERATION. CHANGES TO PROVIDER HL01 VALUE WHEN PROVIDER NUMBER CHANGES IN A TRANSACTION SET. HL03 HIERARCHICAL LEVEL 22 SUBSCRIBER HL04 HIERARCHICAL CHILD 0 NO SUBORDINATE HL SEGMENT IN THIS HIERARCHICAL STRUCTURE SBR SUBSCRIBER SBR01 PAER RESPONSIBILIT U UNKNOWN SEQUENCE NUMBER SBR02 INDIVIDUAL RELATIONSHIP 18 SELF SBR09 CLAIM FILING INDICATOR MC MEDICAID 2010BA SUBSCRIBER NAME NM1 SUBSCRIBER NAME NM101 ENTIT IDENTIFIER IL INSURED OR SUBSCRIBER NM102 ENTIT TPE 1 PERSON NM103 NAME LAST OR ORGANIZATION SUBSCRIBER LAST NAME NAME 12

13 LOOP SEG MENT 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION NM104 NAME FIRST C2 SUBSCRIBER FIRST NAME NM105 NAME MIDDLE SUBSCRIBER MIDDLE INITIAL, IF KNOWN NM108 IDENTIFICATION MI MEMBER IDENTIFICATION NUMBER NM109 IDENTIFICATION DHS ASSIGNED EIGHT DIGIT MEMBER ID N3 SUBSCRIBER ADDRESS C2 SINCE THE PATIENT IS ALWAS THE SUBSCRIBER UNDER MHCP, THIS SEGMENT IS REQUIRED. N301 ADDRESS DEFAULT TO AN TEXT NOT USED BUT REQUIRED B STANDARD. N4 SUBSCRIBER CIT/STATE/ZIP C2 SINCE THE PATIENT IS ALWAS THE SUBSCRIBER UNDER MHCP, THIS SEGMENT IS REQUIRED. N401 CIT NAME DEFAULT TO AN TEXT NOT USED BUT REQUIRED B STANDARD N402 STATE OR PROVINCE C2 DEFAULT TO AN TEXT NOT USED BUT REQUIRED B STANDARD N403 POSTAL C2 DEFAULT TO DMG SUBSCRIBER DEMOGRAPHICS C2 REF PROPERT AND CASUALT CLAIM NUMBER DMG01 DATE TIME PERIOD FORMAT D8 DATE EXPRESSED IN FORMAT CCMMDD DMG02 DATE TIME PERIOD SUBSCRIBER BIRTH DATE DMG03 GENDER U UNKNOWN (DEFAULT) F FEMALE M MALE C2 REF01 REFERENCE IDENTIFICATION 4 AGENC CLAIM NUMBER REF02 REFERENCE IDENTIFICATION MCO S OWN MEMBER ID 2010BB PAER NAME NM1 PAER NAME NM101 ENTIT IDENTIFIER PR PAER NM102 ENTIT TPE 2 NON-PERSON ENTIT NM103 NAME LAST OR ORGANIZATION MN DEPT OF HUMAN SERVICES NAME NM108 IDENTIFICATION PI PAER ID NM109 IDENTIFICATION DHS PAER ID 13

14 LOOP 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION BILLING PROVIDER SECONDAR IDENTIFICATION REF01 REFERENCE IDENTIFICATION G2 (REPLACES 2010AA PA TO PROVIDER UMPI) PROVIDER COMMERCIAL NUMBER REF02 REFERENCE IDENTIFICATION BILLING PROVIDER SECONDAR IDENTIFIER (DHS UMPI NUMBER) 2300 CLAIM CLM CLAIM CLM01 CLAIM SUBMITTER S IDENTIFIER MCO S OWN CLAIM NUMBER (ICN) SEG MENT REF CLM02 MONETAR AMOUNT TOTAL CLAIM CHARGE AMOUNT (BILLED AMOUNT) PER APPENDIX A IN THE IMPLEMENTATION GUIDE, DECIMAL DATA ELEMENTS IN DATA ELEMENT 782 WILL BE LIMITED TO A MAXIMUM LENGTH OF 10 CHARACTERS INCLUDING REPORTED OR IMPLIED PLACES FOR CENTS. CLM05 HEALTH CARE SERVICE LOCATION CLM05 FACILIT VALUE PLACE OF SERVICE 1 CLM05 FACILIT B PLACE OF SERVICE FOR 2 CLM05 3 CLM06 CLM07 CLAIM FREQUENC TPE (CLAIM SUBMISSION REASON ) ES/NO CONDITION OR RESPONSE (PROVIDER SIGNATURE ON FILE) PROVIDER ACCEPT ASSIGNMENT (MEDICARE ASSIGNMENT ) PROFESSIONAL OR DENTAL SERVICES 1 ORIGINAL 7 REPLACEMENT 8 VOID ES (DEFAULT) N NO A ASSIGNED (DEFAULT) B C ASSIGNMENT ACCEPTED FOR CLINICAL LAB SERVICES ONL NOT ASSIGNED 14

15 LOOP SEG MENT 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION CLM08 CLM09 ES/NO CONDITION OR RESPONSE (ASSIGNMENT OF BENEFITS INDICATOR) RELEASE OF ES (DEFAULT) N NO W PATIENT REFUSES TO ASSIGN BENEFITS ES, PROVIDER HAS A SIGNED STATEMENT PERMITTING RELEASE OF MEDICAL BILLING DATA RELATED TO A CLAIM (DEFAULT) I INFORMED CONSENT TO RELEASE MEDICAL FOR CONDITIONS OR DIAGNOSES REGULATED B FEDERAL STATUTES CLM10 CLM11 CLM11 1 CLM11 3 CLM11 4 CLM11 5 PATIENT SIGNATURE SOURCE RELATED CAUSES RELATED CAUSES AA AUTO ACCIDENT P SIGNATURE GENERATED B PROVIDER IF THE PATIENT WAS NOT PHSICALL PRESENT FOR SERVICES EM EMPLOMENT OA OTHER ACCIDENT STATE OR PROVINCE REQUIRED IF CLM11-1, -2 or -3 = AA TO IDENTIF THE STATE IN WHICH THE AUTOMOBILE ACCIDENT OCCURRED. USE THE STATE POSTAL. COUNTR REQUIRED IF THE AUTOMOBILE ACCIDENT OCCURRED OUT OF THE UNITED STATES. DTP ONSET OF CURRENT ILLNESS DTP01 DATE/TIME 431 ONSET OF CURRENT ILLNESS DTP02 DATE TIME PERIOD FORMAT D8 DATE EXPRESSED IN CCMMDD DTP03 DATE TIME PERIOD ONSET OF CURRENT ILLNESS DATE IN CCMMDD FORMAT. 15

16 LOOP 837P HIPAA Implementation Guide Data SEG NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION MENT DTP ACCIDENT DATE DTP01 DATE/TIME 439 ACCIDENT DTP DATE REPRICER RECEIVED DATE DTP02 DATE TIME PERIOD FORMAT D8 DATE EXPRESSED IN CCMMDD DTP03 DATE TIME PERIOD ACCIDENT DATE C2 DATE MCO RECEIVED CLAIM DTP01 DATE/TIME 050 RECEIVED DTP02 DATE TIME PERIOD FORMAT DT DATE AND TIME EXPRESSED IN FORMAT CCMMDDHHMM DTP03 DATE TIME PERIOD MCO RECEIVED DATE AMT PATIENT AMOUNT PAID AMT01 AMOUNT F5 PATIENT AMOUNT PAID. ENTER IF APPLICABLE. AMT02 MONETAR AMOUNT PER APPENDIX A IN THE IMPLEMENTATION GUIDE, DECIMAL DATA ELEMENTS IN DATA ELEMENT 782 WILL BE LIMITED TO A MAXIMUM LENGTH OF 10 CHARACTERS INCLUDING REPORTED OR IMPLIED PLACES FOR CENTS. REF ORIGINAL REFERENCE NUMBER (ICN/DCN) REF01 PAER CLAIM CONTROL F8 ORIGINAL REFERENCE NUMBER NUMBER REF02 REFERENCE IDENTIFICATION MCO S ORIGINAL CLAIM (ICN) NUMBER. USED WHEN CLM05-3 IS 7 REPLACEMENT OR 8-VOID. THIS IS FOR REPLACEMENT CLAIM OR VOID CLAIM USAGE ONL. NTE CLAIM NOTE C2 REQUIRED ICN TRACKING NUMBER WHEN CLAIM IS A CORRECTED VERSION OF A DHS DENIED CLAIM OR VOIDED CLAIM. NTE01 NOTE REFERENCE ADD ADDITIONAL 16

17 LOOP SEG MENT 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION NTE02 DESCRIPTION ICN OF CORRECTED CLAIM FORMAT IS C: (CAPITAL C, COLON, ICN OF CLAIM BEING CORRECTED NO SPACES) CRC EPSDT REFERRAL CRC THIS SEGMENT IS SENT FOR CHILD AND TEEN CHECKUP CLAIMS. CRC01 CATEGOR ZZ MUTUALL DEFINED. EPSDT SCREEN REFERRAL. CRC02 ES/NO CONDITION OR N NO RESPONSE (WAS AN EPSDT REFERRAL GIVEN TO THE PATIENT?) ES CRC03 CONDITION INDICATOR AV AVAILABLE NOT USED. PATIENT REFUSED REFERRAL. NU NOT USED. THIS CONDITION INDICATOR MUST BE USED WHEN THE SUBMITTER ANSWERS N IN CRC02. S2 UNDER TREATMENT-PATIENT IS CURRENTL UNDER TREATMENT FOR REFERRED DIAGNOSTIC OR CORRECTIVE HEALTH PROBLEM. ST NEW SERVICES REQUESTED. REFERRAL TO ANOTHER PROVIDER FOR DIAGNOSTIC OR CORRECTIVE TREATMENT/SCHEDULED FOR ANOTHER APPOINTMENT WITH SCREENING PROVIDER. HI HEALTH CARE S HI01 HEALTH CARE DO NOT SEND DECIMAL POINTS IN THE DIAGNOSIS. HI01-1 LIST BK ICD-9-CM PRINCIPAL DIAGNOSIS ABK ICD-10-CM PRINCIPAL DIAGNOSIS HI01-2 INDUSTR PRINCIPAL DIAGNOSIS HI102 HI12 HEALTH CARE HI02-1 HI12-1 LIST (S) BF ICD-9-CM DIAGNOSIS ABF ICD-10-CM DIAGNOSIS 17

18 LOOP SEG MENT HI 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION HEALTH CARE S HI02-2 HI12-2 HI01 HI12 HI01-1 HI12-1 HI01-2 INDUSTR DIAGNOSIS HEALTH CARE CONDITION LIST BG CONDITION INDUSTR CONDITION HI A REFERRING PROVIDER NAME NM1 INDIVIDUAL /ORG. NAME NM101 ENTIT IDENTIFIER DN REFERRING PROVIDER NM102 ENTIT TPE 1 PERSON NM103 NAME LAST OR ORGANIZATION NAME DEFAULT TO AN TEXT NOT USED BUT REQUIRED B STANDARD NM104 NAME FIRST DEFAULT TO AN TEXT- REQUIRED IF 1 IS SENT IN NM102. NM108 IDENTIFICATION XX NPI NM109 IDENTIFICATION REFERRING PROVIDER NPI REF REFERRING PROVIDER SECONDAR IDENTIFICATION REF01 REFERENCE IDENTIFICATION G2 PROVIDER COMMERCIAL NUMBER REF02 REFERENCE IDENTIFICATION REFERRING PROVIDER SECONDAR IDENTIFIER (DHS UMPI NUMBER). 2310B RENDERING PROVIDER NAME C2 REQUIRED WHEN RENDERING PROVIDER IS DIFFERENT THAN PROVIDER LISTED IN LOOP 2010AA NM1 INDIVIDUAL /ORG. NAME NM101 ENTIT IDENTIFIER 82 RENDERING PROVIDER NM102 ENTIT TPE 1 PERSON 2 NON-PERSON NM103 NAME LAST OR ORGANIZATION NAME DEFAULT TO AN TEXT- NOT USED BUT REQUIRED B STANDARD 18

19 LOOP SEG MENT 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION NM104 NAME FIRST DEFAULT TO AN TEXT- REQUIRED IF 1 IS SENT IN NM102. NM108 IDENTIFICATION XX NPI NM109 IDENTIFICATION RENDERING PROVIDER NPI NUMBER 2310C REF NM1 N3 N4 REF RENDERING PROVIDER SECONDAR IDENTIFICATION SERVICE FACILIT LOCATION NAME SERVICE FACILIT LOCATION NAME SERVICE FACILIT LOCATION ADDRESS SERVICE FACILIT LOCATION CIT, STATE, ZIP SERVICE FACILIT LOCATION SECONDAR IDENTIFICATION C2 REF01 REFERENCE IDENTIFICATION G2 PROVIDER COMMERCIAL NUMBER REF02 REFERENCE IDENTIFICATION RENDERING PROVIDER SECONDAR IDENTIIER (DHS UMPI NUMBER). REQUIRED WHEN THE LOCATION OF HEALTH CARE SERVICE IS DIFFERENT THAN THAT CARRIED IN LOOP 2010AA NM101 ENTIT IDENTIFIER 77 SERVICE LOCATION NM102 ENTIT TPE 2 NON-PERSON ENTIT NM103 NAME LAST OR ORGANIZATION LABORATOR OR FACILIT NAME NAME NM108 IDENTIFICATION XX NPI NM109 IDENTIFICATION LABORATOR OR FACILIT PRIMAR IDENTIFIER N301 ADDRESS LABORATOR OR FACILIT ADDRESS LINE N302 ADDRESS LABORATOR OR FACILIT ADDRESS N401 CIT NAME LABORATOR OR FACILIT CIT NAME N402 STATE OR PROVINCE LABORATOR OR FACILIT STATE OR PROVINCE N403 POSTAL LABORATOR OR FACILIT POSTAL ZONE OR ZIP REF01 REFERENCE IDENTIFICATION G2 PROVIDER COMMERCIAL NUMBER 19

20 LOOP 2310D SEG MENT NM1 REF 837P HIPAA Implementation Guide Data SUPERVISING PROVIDER NAME SUPERVISING PROVIDER NAME NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION SUPERVISING PROVIDER SECONDAR IDENTIFICATION 2320 OTHER SUBSCRIBER SBR OTHER SUBSCRIBER REF02 REFERENCE IDENTIFICATION LABORATOR OR FACILIT SECONDAR IDENTIFIER (DHS UMPI NUMBER) NM101 ENTIT IDENTIFIER DQ SUPERVISING PHSICIAN NM102 ENTIT TPE 1 PERSON NM103 NAME LAST OR ORGANIZATION SUPERVISING PROVIDER LAST NAME NAME NM104 NAME FIRST SUPERVISING PROVIDER FIRST NAME NM108 IDENTIFICATION XX NPI NM109 IDENTIFICATION SUPERVISING PROVIDER IDENTIFIER REF01 REFERENCE IDENTIFICATION G2 PROVIDER COMMERCIAL NUMBER REF02 REFERENCE IDENTIFICATION SUPERVISING PROVIDER SECONDAR IDENTIFIER (DHS UMPI NUMBER) C2 THIS LOOP IS REQUIRED THE FIRST OCCURRENCE MUST CONTAIN FOR THE MCO AS THE PRIMAR/SECONDAR PAER. IF THE PRIMAR PAER IS A THIRD PART, THE SECOND OCCURRENCE OF THIS SEGMENT SHOULD CONTAIN A P AND RELATED TO THE RELEVANT THIRD PART PAER. UP TO 10 SBR LOOPS CAN BE SENT. SBR01 PAER RESPONSIBILIT SEQUENCE NUMBER P PRIMAR S T SEE X12 IG FOR ADDT L S/ VALUES SECONDAR TERTIAR REFER TO THE IMPLEMENTATION GUIDE FOR THE OTHER S/VALUES TO USE. 20

21 LOOP SEG MENT 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION SBR02 INDIVIDUAL RELATIONSHIP 18 SELF this is the only option for the first occurrence. Subsequent occurrences should be billed as appropriate. SEE X12 IG FOR ADDT L S/ VALUES REFER TO THE IMPLEMENTATION GUIDE FOR THE OTHER S/VALUES TO USE. SBR03 REFERENCE IDENTIFICATION INSURANCE GROUP OR POLIC NUMBER SBR05 INSURANCE TPE SEE X12 IG FOR S/ VALUES REQUIRED WHEN MEDICARE PRESENT AND MEDICARE IS NOT PRIMAR PAER. REFER TO THE IMPLEMENTATION GUIDE FOR THE S/VALUES TO USE. SBR09 CLAIM FILING INDICATOR HM HEALTH MAINTENANCE ORGANIZATION (HM) This is only for the first occurrence. On subsequent occurrences, fill out as appropriate. SEE X12 IG FOR ADDT L S/ VALUES REFER TO THE IMPLEMENTATION GUIDE FOR THE OTHER S/VALUES TO USE. CAS CLAIM LEVEL ADJUSTMENTS COMPLETE IF OU HAVE CLAIM LEVEL ADJUSTMENTS CAS01 CLAIM ADJUSTMENT GROUP CO CONTRACTUAL OBLIGATIONS CR OA PI PR CORRECTIONS AND REVERSALS OTHER ADJUSTMENTS PAOR INITIATED REDUCTIONS PATIENT RESPONSIBILIT ADJUSTMENT REASON CAS02 CLAIM ADJUSTMENT REASON CAS03 MONETAR AMOUNT ADJUSTMENT AMOUNT CAS04 QUANTIT ADJUSTMENT QUANTIT IF CLAIM DENIED B MCO, ENTER (SIX EIGHTS) CAS05 CLAIM ADJUSTMENT REASON ADJUSTMENT REASON CAS06 MONETAR AMOUNT ADJUSTMENT AMOUNT 21

22 LOOP SEG MENT 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION CAS07 QUANTIT ADJUSTMENT QUANTIT IF CLAIM DENIED B MCO, ENTER (SIX EIGHTS) CAS08 CLAIM ADJUSTMENT REASON ADJUSTMENT REASON CAS09 MONETAR AMOUNT ADJUSTMENT AMOUNT CAS10 QUANTIT ADJUSTMENT QUANTIT IF CLAIM DENIED B MCO, ENTER (SIX EIGHTS) CAS11 CLAIM ADJUSTMENT REASON ADJUSTMENT REASON CAS12 MONETAR AMOUNT ADJUSTMENT AMOUNT CAS13 QUANTIT ADJUSTMENT QUANTIT IF CLAIM DENIED B MCO, ENTER (SIX EIGHTS) CAS14 CLAIM ADJUSTMENT REASON ADJUSTMENT REASON CAS15 MONETAR AMOUNT ADJUSTMENT AMOUNT CAS16 QUANTIT ADJUSTMENT QUANTIT IF CLAIM DENIED B MCO, ENTER (SIX EIGHTS) CAS17 CLAIM ADJUSTMENT REASON ADJUSTMENT REASON CAS18 MONETAR AMOUNT ADJUSTMENT AMOUNT CAS19 QUANTIT ADJUSTMENT QUANTIT IF CLAIM DENIED B MCO, ENTER (SIX EIGHTS) AMT COB PAER PAID AMOUNT C2 AMT01 AMOUNT D PAOR PAID AMOUNT AMT02 MONETAR AMOUNT PAER PAID AMOUNT; ZERO IS ACCEPTABLE AMT REMAINING PATIENT LIABILIT AMT01 AMOUNT EAF AMOUNT OWED AMT02 MONETAR AMOUNT REMAINING PATIENT LIABILIT AMT OI COB TOTAL NON-COVERED AMOUNT OTHER INSURANCE COVERAGE AMT01 AMOUNT A8 NONCOVERED CHARGES ACTUAL AMT02 MONETAR AMOUNT NON-COVERED CHARGE AMOUNT OI03 ES/NO CONDITION OR RESPONSE 22

23 LOOP SEG MENT 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION OI04 PATIENT SIGNATURE SOURCE P SIGNATURE GENERATED B PROVIDER AS THE PATIENT WAS NOT PHSICALL PRESENT FOR SERVICES OI06 RELEASE OF 2330A OTHER SUBSCRIBER NAME C2 THIS LOOP IS REQUIRED MCO ADJUDICATION AS A PAER IS SUBMITTED HERE AND TPL ADJUDICATION. ONE SUBSCRIBER NAME PER SBR SEGMENT. NM1 OTHER SUBSCRIBER NAME NM101 ENTIT ID IL INSURED OR SUBSCRIBER NM102 ENTIT TPE 1 PERSON 2 NON-PERSON ENTIT NM103 NAME LAST OR ORGANIZATION NAME OTHER INSURED LAST NAME IF NM102= 2, THEN EITHER THE ORGANIZATION NAME OR UNKNOWN IS VALID. NM104 NAME FIRST OTHER INSURED FIRST NAME NM105 NAME MIDDLE OTHER INSURED MIDDLE INITIAL NAME NM107 NAME SUFFIX OTHER INSURED NAME SUFFIX NM108 ID MI MEMBER IDENTIFICATION NUMBER NM109 ID EITHER THE OTHER INSURED IDENTIFIER OR UNKNOWN IS VALID. 2330B OTHER PAER NAME C2 THIS LOOP IS REQUIRED MCO ADJUDICATION AS A PAER IS SUBMITTED HERE AND TPL ADJUDICATION. ONE OTHER PAER NAME PER SBR SEGMENT. NM1 OTHER PAER NAME NM101 ENTIT IDENTIFIER PR PAER NM102 ENTIT TPE 2 NON-PERSON ENTIT NM103 NAME LAST OR ORGANIZATION NAME EITHER THE ORGANIZATION NAME OR UNKNOWN IS VALID. NM108 IDENTIFICATION PI PAOR IDENTIFICATION NM109 IDENTIFICATION OTHER PAER PRIMAR IDENTIFIER DTP CLAIM CHECK OR REMITTANCE DATE DTP01 DATE/TIME 573 DATE CLAIM PAID 23

24 LOOP SEG MENT REF 837P HIPAA Implementation Guide Data OTHER PAER CLAIM CONTROL NUMBER NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION DTP02 DATE TIME PERIOD FORMAT D8 DATE EXPRESSED IN CCMMDD DTP03 DATE TIME PERIOD ADJUDICATION OR PAMENT DATE MUST BE USED FOR MEDICARE CLAIMS. REF01 REFERENCE IDENTIFICATION F8 ORIGINAL REFERENCE NUMBER REF02 REFERENCE IDENTIFICATION MEDICARE ICN 2400 SERVICE LINE LX SERVICE LINE LX01 ASSIGNED NUMBER BEGIN WITH 1 AND INCREMENT B 1. SV1 PROFESSIONAL SERVICE SV101 SV101 1 SV101 2 SV101 3 SV101 4 SV101 5 SV101 6 SV101 7 COMPOSITE MEDICAL PROCEDURE IDENTIFIER PRODUCT/SERVICE ID HC HCPCS/CPT PRODUCT/SERVICE ID HCPCS/CPT PROCEDURE PROCEDURE MODIFIER MODIFIER 1 PROCEDURE MODIFIER MODIFIER 2 PROCEDURE MODIFIER MODIFIER 3 PROCEDURE MODIFIER MODIFIER 4 DESCRIPTION DESCRIPTION OF NON SPECIFIC, (NOC), UNLISTED, UNCLASSIFIED OR MISCELLANEOUS S WHEN REPORTED IN SV OU SHOULD ALSO REPORT THE HEARING AID MODEL NUMBER IN THIS DATA ELEMENT (NOT IN THE L2300/K3 SEGMENT). SV102 MONETAR AMOUNT LINE ITEM CHARGE AMOUNT. PER APPENDIX A IN THE IMPLEMENTATION GUIDE, DECIMAL DATA ELEMENTS IN DATA ELEMENT 782 WILL BE LIMITED TO A MAXIMUM LENGTH OF 10 CHARACTERS INCLUDING REPORTED OR IMPLIED PLACES FOR CENTS. 24

25 LOOP SEG MENT 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION SV103 UNIT/BASIS OF MEASUREMENT UN UNITS MJ MINUTES-USED FOR ANESTHESIA CLAIMS SV104 QUANTIT UNITS OF SERVICE SV105 FACILIT VALUE OVERRIDE CLM05-1 IN LOOP 2300 WHEN PLACE OF SERVICE IS DIFFERENT THAN THE VALUE SENT AT THE CLAIM LEVEL. SV107 COMP. DIAGNOSIS POINTER SV107 1 DIAGNOSIS POINTER POINTER TO RELATED DIAGNOSIS SV107 2 DIAGNOSIS POINTER POINTER TO RELATED DIAGNOSIS SV107 3 DIAGNOSIS POINTER POINTER TO RELATED DIAGNOSIS SV107 4 DIAGNOSIS POINTER POINTER TO RELATED DIAGNOSIS SV109 ES/NO CONDITION OR RESPONSE EMERGENC RELATED DTP DATE SERVICE DATE DTP01 DATE/TIME 472 SERVICE DATE(S) DTP02 DATE TIME PERIOD FORMAT D8 DATE EXPRESSED IN CCMMDD RD8 DATE EXPRESSED IN CCMMDD CCMMDD DTP03 DATE TIME PERIOD SERVICE DATE(S) DTP CERTIFICATION REVISION DATE C2 MCO PAID DATE DTP01 RECERTIFICATION DATE 607 PAID DATE DTP02 D8 DATE EXPRESSED IN CCMMDD DTP03 DATE OF PAMENT QT AMBULANCE PATIENT COUNT C2 QT01 QUANTIT PT PATIENTS QT02 QUANTIT AMBULANCE PATIENT COUNT. REQUIRED WHEN MORE THAN ONE PATIENT IS TRANSPORTED IN THE SAME VEHICLE FOR AMBULANCE OR NON-EMERGENC TRANSPORTATION SERVICES. 25

26 LOOP REF 837P HIPAA Implementation Guide Data REPRICED LINE ITEM REFERENCE NUMBER NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER C2 REF01 REFERENCE IDENTIFICATION 9B ALLOWED AMOUNT REF02 MONETAR AMOUNT ALLOWED AMOUNT IS THE PROVIDER CONTRACTED RATE PRIOR TO AN EXCLUSIONS OR ADD-ONS. SEE APPENDIX P. 85 C2 REF01 REFERENCE IDENTIFICATION 9D PAID AMOUNT QUALIFER REF02 MONETAR AMOUNT THE AMOUNT PAID TO THE PROVIDER EXCLUDING THIRD PART LIABILIT, PROVIDER WITHHOLDS AND INCENTIVES, AND MEMBER COST SHARING. SEE APPENDIX P. 85 REF LINE ITEM CONTROL NUMBER REF01 REFERENCE IDENTIFICATION 6R PROVIDER CONTROL NUMBER QUALIFER REF02 REFERENCE IDENTIFICATION LINE ITEM CONTROL NUMBER K3 FILE K3 K301 FIXED FORMAT FOR STATE OF JURISDICTION AND TOOTH NUMBER/ORAL CAVIT DRUG IDENTIFICATION C2 USED WHEN PROC MATCHES ONE ON LIST: HS16_147971# LIN ITEM IDENTIFICATION C2 LIN02 PRODUCT/SERVICE ID N4 NATIONAL DRUG LIN03 PRODUCT SERVICE ID NDC FOR PHSICIAN ADMINISTERED DRUGS. CTP DRUG PRICING C2 CTP04 QUANTIT DRUG QUANTIT FOR PHSICIAN ADMINISTERED DRUGS. CTP05 COMPOSITE UNIT OF MEASURE UNIT OR BASIS FOR MEASUREMENT SEG MENT REF CTP05 1 UNIT OR BASIS OF MEASUREMENT F2 INTERNATIONAL UNIT GR GRAM 26

27 LOOP SEG MENT 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION ME MILLIGRAM ML UN MILLILITER UNIT 2420A RENDERING PROVIDER NAME OVERRIDE 2310B LOOP IF THE RENDERING PROVIDER ON A LINE ITEM IS DIFFERENT THAN THE NUMBER SUBMITTED AT THE CLAIM LEVEL. NM1 REF RENDERING PROVIDER NAME RENDERING PROVIDER SECONDAR IDENTIFICATION NM101 ENTIT IDENTIFIER 82 RENDERING PROVIDER NM102 ENTIT TPE 1 PERSON 2 NON-PERSON NM103 NAME LAST OR ORGANIZATION RENDERING PROVIDER LAST NAME NAME NM104 NAME FIRST RENDERING PROVIDER FIRST NAME REQUIRED IF 1 IS SENT IN NM102. NM108 IDENTIFICATION XX NPI NM109 IDENTIFICATION RENDERING PROVIDER IDENTIFIER REF01 REFERENCE IDENTIFICATION G2 PROVIDER COMMERCIAL NUMBER 2420D NM1 SUPERVISING PROVIDER NAME SUPERVISING PROVIDER NAME REF02 REFERENCE IDENTIFICATION RENDERING PROVIDER SECONDAR IDENTIFIER (DHS UMPI NUMBER) NM101 ENTIT IDENTIFIER DQ SUPERVISING PHSICIAN NM102 ENTIT TPE 1 PERSON NM103 NAME LAST OR ORGANIZATION SUPERVISING PROVIDER LAST NAME NAME NM104 NAME FIRST SUPERVISING PROVIDER FIRST NAME REQUIRED IF 1 IS SENT IN NM102. NM108 IDENTIFICATION XX NPI NM109 IDENTIFICATION SUPERVISING PROVIDER IDENTIFIER 27

28 LOOP SEG MENT REF 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION SUPERVISING PROVIDER SECONDAR IDENTIFICATION REF01 REFERENCE IDENTIFICATION G2 PROVIDER COMMERCIAL NUMBER REF02 REFERENCE IDENTIFICATION SUPERVISING PROVIDER SECONDAR IDENTIFIER (DHS UMPI NUMBER) 2420E ORDERING PROVIDER NAME NM1 REF ORDERING PROVIDER NAME ORDERING PROVIDER SECONDAR IDENTIFICATION NM101 ENTIT IDENTIFIER DK ORDERING PHSICIAN NM102 ENTIT TPE 1 PERSON NM103 NAME LAST OR ORGANIZATION ORDERING PROVIDER LAST NAME NAME NM104 NAME FIRST ORDERING PROVIDER FIRST NAME REQUIRED IF 1 IS SENT IN NM102. NM108 IDENTIFICATION XX NPI NM109 IDENTIFICATION ORDERING PROVIDER IDENTIFIER REF01 REFERENCE IDENTIFICATION G2 PROVIDER COMMERCIAL NUMBER REF02 REFERENCE IDENTIFICATION ORDERING PROVIDER SECONDAR IDENTIFIER (DHS UMPI NUMBER) 2420F REFERRING PROVIDER NAME NM1 REF REFERRING PROVIDER NAME REFERRING PROVIDER SECONDAR IDENTIFICATION NM101 ENTIT IDENTIFIER DN REFERRING PROVIDER NM102 ENTIT TPE 1 PERSON NM103 NAME LAST OR ORGANIZATION REFERRING PROVIDER LAST NAME NAME NM104 NAME FIRST REFERRING PROVIDER FIRST NAME REQUIRED IF 1 IS SENT IN NM102. NM108 IDENTIFICATION XX NPI NM109 IDENTIFICATION REFERRING PROVIDER IDENTIFIER REF01 REFERENCE IDENTIFICATION G2 PROVIDER COMMERCIAL NUMBER REF02 REFERENCE IDENTIFICATION REFERRING PROVIDER SECONDAR IDENTIFIER (DHS UMPI NUMBER) 28

29 837P HIPAA Implementation Guide Data LOOP SEG NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION MENT 2430 LINE ADJUDICATION C2 THIS LOOP IS REQUIRED MCO ADJUDICATION AS A PAER IS SUBMITTED HERE AND TPL ADJUDICATION. UP TO 15 OF THIS LOOP CAN BE SENT; SEND ONE PER L2330B/NM1*PR SEGMENT. SVD LINE ADJUDICATION SVD01 IDENTIFICATION OTHER PAER PRIMAR IDENTIFIER SVD02 MONETAR AMOUNT SVD03 COMPOSITE MEDICAL PROCEDURE SVD03 PRODUCT/SERVICE ID HC HCPCS 1 SVD03 PRODUCT SERVICE ID HCPCS PROCEDURE 2 SVD03 PROCEDURE MODIFIER MODIFIER 1 3 SVD03 PROCEDURE MODIFIER MODIFIER 2 4 SVD03 PROCEDURE MODIFIER MODIFIER 3 5 SVD03 PROCEDURE MODIFIER MODIFIER 4 6 SVD05 QUANTIT UNITS OF SERVICE CAS LINE ADJUSTMENT CAS01 CLAIM ADJUSTMENT GROUP CO CONTRACTUAL OBLIGATIONS CR CORRECTION AND REVERSALS OA OTHER ADJUSTMENTS PI PAOR INITIATED REDUCTIONS PR PATIENT RESPONSIBILIT CAS02 CLAIM ADJUSTMENT REASON ADJUSTMENT REASON CAS03 MONETAR AMOUNT ADJUSTMENT AMOUNT CAS04 QUANTIT ADJUSTMENT QUANTIT IF CLAIM DENIED B MCO, ENTER (SIX EIGHTS) CAS05 CLAIM ADJUSTMENT REASON ADJUSTMENT REASON CAS06 MONETAR AMOUNT ADJUSTMENT AMOUNT 29

30 LOOP TRL SEG MENT DTP 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION LINE CHECK OR REMITTANCE DATE CAS07 QUANTIT ADJUSTMENT QUANTIT IF CLAIM DENIED B MCO, ENTER (SIX EIGHTS) CAS08 CLAIM ADJUSTMENT REASON ADJUSTMENT REASON CAS09 MONETAR AMOUNT ADJUSTMENT AMOUNT CAS10 QUANTIT ADJUSTMENT QUANTIT IF CLAIM DENIED B MCO, ENTER (SIX EIGHTS) CAS11 CLAIM ADJUSTMENT REASON ADJUSTMENT REASON CAS12 MONETAR AMOUNT ADJUSTMENT AMOUNT CAS13 QUANTIT ADJUSTMENT QUANTIT IF CLAIM DENIED B MCO, ENTER (SIX EIGHTS) CAS14 CLAIM ADJUSTMENT REASON ADJUSTMENT REASON CAS15 MONETAR AMOUNT ADJUSTMENT AMOUNT CAS16 QUANTIT ADJUSTMENT QUANTIT IF CLAIM DENIED B MCO, ENTER (SIX EIGHTS) CAS17 CLAIM ADJUSTMENT REASON ADJUSTMENT REASON CAS18 MONETAR AMOUNT ADJUSTMENT AMOUNT CAS19 QUANTIT ADJUSTMENT QUANTIT IF CLAIM DENIED B MCO, ENTER (SIX EIGHTS) MEDICARE OR PAER PAID DATE Correction of segment title and REQ value based on review of X12 implementation guide. DTP01 DATE/TIME 573 DATE CLAIM PAID DTP02 DATE TIME PERIOD FORMAT D8 DATE EXPRESSED IN FORMAT CCMMDD DTP03 DATE TIME PERIOD ADJUDICATION OR PAMENT DATE AMT REMAINING PATIENT LIABILIT AMT01 AMOUNT EAF AMOUNT OWED AMT02 MONETAR AMOUNT REMAINING PATIENT LIABILIT TRAILER SE TRANSACTION SET TRAILER SE01 NUMBER OF INCLUDED SEGMENTS TOTAL SEGMENTS IN TRANSACTION SET. 30

31 LOOP SEG MENT 837P HIPAA Implementation Guide Data NAME ID ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION SE02 TRANSACTION SET CONTROL NUMBER MUST MATCH ST02. 31

32 ENVELOPE INTERCHANGE CONTROL HEADER REFERENCE DESCRIPTION ELEMENT DESCRIPTION 837P VALUES DO NOT SEND SEGMENT DELIMITERS THAT ARE MORE THAN ONE BTE. SEE APPENDIX A THROUGH A IN THE 837 IMPLEMENTATION GUIDE FOR LISTS OF CHARACTERS THAT ARE ALLOWED. IF OU SEND CHARACTERS THAT ARE NOT WITHIN THE SETS SHOWN IN THE GUIDE, OUR FILE WILL NOT BE PROCESSED. VALUES ARE CASE SENSITIVE. IF LOWER CASE VALUES ARE SENT, OUR FILE WILL NOT BE PROCESSED. PLEASE SEND ONE INTERCHANGE PER FILE UNTIL FURTHER NOTICE. IF OU SEND MORE THAN ONE INTERCHANGE, THE ADDITIONAL INTERCHANGES MA NOT BE PROCESSED. ISA01 AUTHORIZATION 00-NO AUTHORIZATION PRESENT. ISA02 AUTHORIZATION 10 SPACES ISA03 SECURIT 00-NO SECURIT PRESENT ISA04 SECURIT 10 SPACES ISA05 INTERCHANGE ID ZZ-MUTUALL DEFINED ISA06 INTERCHANGE SENDER ID THIS NUMBER MUST BE THE ONE USED TO REGISTER IN THE MN-ITS SSTEM AND MUST CORRESPOND TO THE MN-ITS MAILBOX NUMBER. THIS MUST CHANGE TO THE 10-DIGIT NATIONAL PROVIDER IDENTIFIER (NPI) OR UNIVERSAL MINNESOTA PROVIDER IDENTIFIER (UMPI) FOLLOWED B 5 TRAILING SPACES. ISA07 INTERCHANGE ID 30-U.S. FEDERAL TAX IDENTIFICATION NUMBER ISA08 INTERCHANGE RECEIVER ID MN DEPT OF HUMAN SERVICES FEIN FOLLOWED B 5 TRAILING SPACES. THIS NUMBER MUST CONTAIN A HPHEN. ISA09 INTERCHANGE DATE CURRENT DATE FORMATTED AS 6-DIGITS (MMDD) ISA10 INTERCHANGE TIME CURRENT TIME FORMATTED AS 4-DIGITS(HHMM) ISA11 REPETITION SEPARATOR PLEASE SEND DHS [ ISA12 INTERCHANGE CONTROL VERSION DRAFT STANDARDS FOR TRIAL USE APPROVED ASC X-12 REVIEW BOARD NUMBER ISA13 INTERCHANGE CONTROL NUMBER BEGIN WITH "1" 9-DIGIT ZERO FILLED LEFT TO RIGHT. ALL ZEROS IS NOT AN ALLOWED VALUE. ISA14 ACKNOWLEDGMENT REQUESTED PROVIDER OPTION 0-NO OR 1-ES. ISA15 USAGE INDICATOR SEND P-PRODUCTION DATE FOR PRODUCTION FILES AND T-TEST DATA FOR TEST FILES. ISA16 COMPONENT ELEMENT SEPARATOR PROVIDER OPTION/SUB-ELEMENT DELIMITER. 32

33 INTERCHANGE CONTROL TRAILER REFERENCE DESCRIPTION ELEMENT DESCRIPTION 837P VALUES IEA01 NUMBER OF INCLUDED FUNCTIONAL PROVIDER TRANSLATOR COUNTS NUMBER OF FUNCTIONAL GROUPS WITHIN THE GROUPS INTERCHANGE. IEA02 INTERCHANGE CONTROL NUMBER SAME AS ISA13 FUNCTIONAL GROUP HEADER REFERENCE DESCRIPTION ELEMENT DESCRIPTION 837P VALUES GS01 FUNCTIONAL IDENTIFIER HC-HEALTH CARE CLAIMS (837) GS02 APPLICATION SENDER S THIS MUST CHANGE TO 10-DIGIT NATIONAL PROVIDER IDENTIFIOER OR UNIVERSAL MINNESOTA PROVIDER IDENTIFIER (UMPI). MUST MATCH THE NUMBER IN ISA06 WITHOUT THE TRAILING SPACES. GS03 APPLICATION RECEIVER S MN DEPT OF HUMAN SERVICES FEIN. THIS NUMBER MUST CONTAIN A HPHEN. GS04 FUNCTIONAL GROUP CREATION DATE CURRENT DATE FORMATTED AS 8-DIGITS (CCMMDD). GS05 CREATION TIME CURRENT TIME FORMATTED AS 4-DIGITS (HHMM). GS06 GROUP CONTROL NUMBER UNIQUE 1-DIGIT TO 9-DIGIT NUMBER. PREFERABL START AT 1 AND INCREMENT B 1 FOR EACH SUCCESSIVE FUNCTIONAL GROUP FROM SENDER TO RECEIVER, AND NOT RESET TO STARTING VALUE OF 1 WITHIN EACH INTERCHANGE OR EACH DA. GS07 RESPONSIBLE AGENC X-ACCREDITED STANDARDS COMMITTEE X-12 GS08 VERSION/RELEASE/INDUSTR IDENTIFIER X222A1DRAFT STANDARDS APPROVED B ASC X12 BOARD. FUNCTIONAL GROUP TRAILER REFERENCE ELEMENT DESCRIPTION 837P VALUES DESCRIPTION GE01 NUMBER OF TRANSACTION SETS INCLUDED 1-6 DIGITS. PROVIDER TRANSLATOR COUNTS NUMBER OF TRANSACTION SETS WITHIN THE FUNCTIONAL GROUP. GE02 GROUP CONTROL NUMBER MUST MATCH GS06 NUMBER. 33

34 3 INSTITUTIONAL 837I HIPAA Implementation Guide Data HDR HEADER ST TRANSACTION SET HEADER ST01 TRANSACTION SET IDENTIFIER 837 HEALTH CARE CLAIM ST02 TRANSACTION SET CONTROL MCO SSTEM GENERATED NUMBER ST03 NUMBER IMPLEMENTATION CONVENTION REFERENCE X223A2 837I VERSION NUMBER BHT BEGIN OF HIERARCHICAL TXN BHT01 HIERARCHICAL STRUCTURE 0019 SOURCE, SUBSCRIBER DEPENDENT BHT02 TRANSACTION SET PURPOSE 00 ORIGINAL 18 REISSUE BHT03 REFERENCE IDENTIFICATION SUBMISSION NUMBER-MCO ASSIGNED BHT04 DATE TRANSACTION SET CREATION DATE BHT05 TIME TRANSACTION SET CREATION TIME BHT06 TRANSACTION TPE RP REPORTING 1000A SUBMITTER NAME THIS LOOP IS USED FOR REGARDING THE MCO RESPONSIBLE FOR THE ENCOUNTER. NM1 SUBMITTER NAME NM101 ENTIT IDENTIFIER 41 SUBMITTER NM102 ENTIT TPE 2 NON-PERSON ENTIT NM103 NAME LAST OR MCO (OR CONTRACTOR) NAME ORGANIZATION NAME NM108 IDENTIFICATION 46 TRADING PARTNER ID NM109 IDENTIFICATION MCO UMPI NUMBER PER SUBMITTER EDI CONTACT INFO PER01 CONTACT FUNCTION IC CONTACT PER02 NAME MCO SUBMITTER CONTACT PER03 COMMUNICATION NUMBER TE TELEPHONE PER04 COMMUNICATION NUMBER MCO CONTACT PHONE NUMBER 34

35 837I HIPAA Implementation Guide Data 1000B RECEIVER NAME NM1 RECEIVER NAME NM101 ENTIT IDENTIFIER 40 RECEIVER NM102 ENTIT TPE 2 NON-PERSON ENTIT NM103 NAME LAST OR MN DEPT OF HUMAN SERVICES ORGANIZATION NAME NM108 IDENTIFICATION 46 TRADING PARTNER ID NM109 IDENTIFICATION RECEIVER ID A BILLING/PA-TO PROVIDER HIERARCHICAL LEVEL HL HIERARCHICAL LEVEL HL01 HIERARCHICAL ID NUMBER 1 THEN INCREMENT B 1. HL03 HIERARCHICAL LEVEL 20 SOURCE HL04 HIERARCHICAL CHILD 1 ADDITIONAL SUBORDINATE HL DATA SEGMENT IN THIS HIERARCHICAL STRUCTURE PRV BILLING PROVIDER SPECIALT PRV01 PROVIDER BI BILLING PRV02 REFERENCE IDENTIFICATION PXC HEALTH CARE PROVIDER TAXONOM PRV03 REFERENCE IDENTIFICATION PROVIDER TAXONOM 2010AA BILLING PROVIDER NAME NM1 BILLING PROVIDER NAME NM101 ENTIT IDENTIFIER 85 BILLING PROVIDER NM102 ENTIT TPE 2 NON-PERSON ENTIT NM103 NAME LAST OR ORGANIZATION NAME BILLING PROVIDER ORGANIZATIONAL NAME NM108 IDENTIFICATION XX CMS NATIONAL PROVIDER IDENTIFIER (NPI) NM109 IDENTIFICATION NATIONAL PROVIDER IDENTIFIER (NPI) N3 BILLING PROVIDER ADDRESS N301 ADDRESS BILLING PROVIDER ADDRESS LINE N302 ADDRESS BILLING PROVIDER ADDRESS LINE N4 BILLING PROVIDERCIT/STATE/ZIP N401 CIT NAME BILLING PROVIDER CIT NAME 35

36 837I HIPAA Implementation Guide Data N402 STATE OR PROVINCE BILLING PROVIDER STATE OR PROVINCE N403 POSTAL BILLING PROVIDER POSTAL ZONE OR ZIP 2000B REF BILLING PROVIDER TAX IDENTIFICATION REF01 REFERENCE IDENTIFICATION BILLING PROVIDER TAX IDENTIFICATION EI EMPLOER IDENTIFICATION NUMBER OR DEFAULT TO AN NUMBER REQUIRED B STANDARD REFERENCE IDENTIFICATION ID NUMBER SUBSCRIBER HIERARCHICAL LEVEL HL HIERARCHICAL LEVEL HL01 HIERARCHICAL ID NUMBER START WITH 2 AND INCREMENT B 1. HL02 HIERARCHICAL PARENT ID 1 FOR FIRST ITERATION. CHANGES TO PROVIDER HL01 VALUE WHEN PROVIDER NUMBER CHANGES IN A TRANSACTION SET. HL03 HIERARCHICAL LEVEL 22 SUBSCRIBER HL04 HIERARCHICAL CHILD 0 NO SUBORDINATE HL SEGMENT IN THIS HIERARCHICAL STRUCTURE SBR SUBSCRIBER SBR01 PAER RESPONSIBILIT U UNKNOWN SEQUENCE NUMBER SBR02 INDIVIDUAL RELATIONSHIP 18 SELF SBR09 CLAIM FILE INDICATOR MC MEDICAID 2010BA SUBSCRIBER NAME NM1 SUBSCRIBER NAME NM101 ENTIT IDENTIFIER IL INSURED OR SUBSCRIBER NM102 ENTIT TPE 1 PERSON NM103 NAME LAST OR MEMBER LAST NAME ORGANIZATION NAME NM104 NAME FIRST MEMBER FIRST NAME NM105 NAME MIDDLE MEMBER MIDDLE INITIAL, IF KNOWN NM108 IDENTIFICATION MI MEMBER ID NUMBER 36

37 837I HIPAA Implementation Guide Data NM109 IDENTIFICATION DHS ASSIGNED EIGHT DIGIT MEMBER ID SUBSCRIBER ADDRESS C2 SINCE THE PATIENT IS ALWAS THE SUBSCRIBER UNDER MHCP, THIS SEGMENT IS REQUIRED. N3 SUBSCRIBER ADDRESS N301 ADDRESS DEFAULT TO AN TEXT NOT USED BUT REQUIRED B STANDARD. SUBSCRIBER CIT/STATE/ZIP C2 SINCE THE PATIENT IS ALWAS THE SUBSCRIBER UNDER MHCP, THIS SEGMENT IS REQUIRED. N4 SUBSCRIBER CIT, STATE, ZIP N401 SUBSCRIBER CIT DEFAULT TO AN TEXT NOT USED BUT REQUIRED B STANDARD N402 SUBSCRIBER STATE DEFAULT TO AN TEXT NOT USED BUT REQUIRED B STANDARD N403 SUBSCRIBER ZIP DEFAULT TO DMG SUBSCRIBER DEMOGRAPHICS DMG0 DATE TIME FORMAT D8 DATE EXPRESSED IN CCMMDD 1 DMG0 DATE TIME PERIOD SUBSCRIBER BIRTH DATE 2 DMG0 3 GENDER U UNKNOWN (DEFAULT) REF PROPERT AND CASUALT CLAIM NUMBER C2 F M FEMALE MALE REF01 REFERENCE IDENTIFICATION 4 AGENC CLAIM NUMBER REF02 REFERENCE IDENTIFICATION MCO S OWN MEMBER NUMBER 2010BB PAER NAME NM1 PAER NAME y NM101 ENTIT IDENTIFIER PR PAER NM102 ENTIT TPE 2 NON-PERSON ENTIT NM103 NAME LAST OR ORGANIZATION NAME NM108 IDENTIFICATION NM109 IDENTIFICATION PI PAER ID MN DEPT OF HUMAN SERVICES DHS PAER ID 37

38 837I HIPAA Implementation Guide Data REF BILLING PROVIDER SECONDAR IDENTIFICATION REF01 REFERENCE IDENTIFICATION G2 (REPLACES 2010AA PA TO PROVIDER UMPI) PROVIDER COMMERCIAL NUMBER REF02 REFERENCE IDENTIFICATION BILLING PROVIDER SECONDAR IDENTIFIER (DHS UMPI NUMBER) 2300 CLAIM CLM CLAIM CLM01 CLAIM SUBMITTER S MCO S OWN CLAIM NUMBER (ICN) IDENTIFIER CLM02 MONETAR AMOUNT TOTAL CLAIM CHARGE AMOUNT (BILLED AMOUNT) PER APPENDIX A IN THE IMPLEMENTATION GUIDE, DECIMAL DATA ELEMENTS IN DATA ELEMENT 782 WILL BE LIMITED TO A MAXIMUM LENGTH OF 10 CHARACTERS INCLUDING REPORTED OR IMPLIED PLACES FOR CENTS. MUST BE GREATER THAN OR EQUAL TO ZERO CLM05 CLM05-1 CLM05-2 CLM05-3 HEALTH CARE SERVICE FACILIT VALUE LOCATION FACILIT VALUE FIRST TWO DIGITS OF THE TPE OF BILL FACILIT A UNIFORM BILLING CLAIM FORM BILL TPE CLAIM FREQUENC TPE CLAIM FREQUENC TPE, SPECIFING THE FREQUENC OF THE CLAIM; THIS IS THE THIRD POSITION OF THE UNIFORM BILLING CLAIM FORM BILL TPE SOURCE ADMIT DISCHARGE 2 INTERIM-FIRST CLAIM 3 INTERIM-CONTINUING CLAIM 4 INTERIM-LAST CLAIM 5 LATE CHARGES 38

39 837I HIPAA Implementation Guide Data 7 REPLACEMENT 8 VOID CLM06 CLM07 CLM08 ES/NO CONDITION OR RESPONSE (PROVIDER SIGNATURE ON FILE) PROVIDER ACCEPT ASSIGNMENT ES/NO CONDITION OR RESPONSE N/U THIS DATA ELEMENT IS NO LONGER USED. N NO A ASSIGNED (DEFAULT) B C ES (DEFAULT) N ACCEPTS ASSIGNMENT ON CLINICAL LAB SERVICES ONL NOT ASSIGNED W NOT APPLICABLE (USE W FOR PATIENT REFUSAL) CLM09 RELEASE OF ES, PROVIDER HAS A SIGNED STATEMENT PERMITTING RELEASE OF MEDICAL BILLING DATA RELATED TO A CLAIM (DEFAULT) I INFORMED CONSENT TO RELEASE MEDICAL FOR CONDITIONS OR DIAGNOSES REGULATED B FEDERAL STATUTES. DTP DISCHARGE HOUR DTP01 DATE/TIME 096 DISCHARGE DTP02 DATE TIME PERIOD FORMAT TM TIME EXPRESSED IN FORMAT HHMM DTP03 DATE TIME PERIOD DISCHARGE TIME VALUE CAN BE DEFAULTED TO 00. DTP STATEMENT DATES DTP01 DATE/TIME 434 STATEMENT DTP02 DATE TIME PERIOD FORMAT RD8 DATE EXPRESSED IN CCMMDD CCMMDD. WHEN THE STATEMENT IS FOR A SINGLE DATE OF SERVICE, THE FROM AND THROUGH DATE ARE THE SAME. DTP03 DATE TIME PERIOD STATEMENT FROM AND TO NO 39

40 837I HIPAA Implementation Guide Data DTP ADMISSION DATE/HOUR DTP01 DATE/TIME 435 ADMISSION DTP02 DATE TIME PERIOD FORMAT DT DATE AND TIME EXPRESSED IN FORMAT CCMMDDHHMM DTP03 DATE TIME PERIOD ADMISSION DATE AND HOUR DTP DATE REPRICER RECEIVED DATE C2 DATE MCO RECEIVED CLAIM DTP01 DATE/TIME 050 RECEIVED DTP02 DATE TIME PERIOD FORMAT DT DATE AND TIME EXPRESSED IN FORMAT CCMMDDHHMM DTP03 DATE TIME PERIOD MCO RECEIVED DATE CL1 INSTITUTIONAL CLAIM CL101 PRIORIT (TPE) OF ADMISSION OR VISIT CL102 POINT OF ORIGIN FOR ADMISSION OR VISIT AMT PATIENT ESTIMATED AMOUNT DUE ADMISSION TPE REQUIRED FOR ALL INPATIENT AND OUTPATIENT SERVICES ADMISSION SOURCE REQUIRED FOR ALL INPATIENT AND OUTPATIENT SERVICES CL103 PATIENT STATUS PATIENT STATUS LIST 239 : Follow HIPAA guide for all claims except CD residential C2: Required for CD residential treatment claims AMT01 AMOUNT F3 PATIENT RESPONSIBILIT IF APPLICABLE AMT02 MONETAR AMOUNT REF PAER CLAIM CONTROL NUMBER REF01 REFERENCE IDENTIFICATION F8 ORIGINAL REFERENCE NUMBER REF02 REFERENCE IDENTIFICATION MCO S ORIGINAL CLAIM (ICN) NUMBER. USED WHEN CLM05-3 IS 7 REPLACEMENT OR 8-VOID. THIS IS FOR REPLACEMENT CLAIM OR VOID CLAIM USAGE ONL. 40