837 Institutional Health Care Claim Outbound

Transcription

1 837I This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained in this document are supplemental and should be used in conjunction with the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3) as published by the Washington Publishing Company. Section 1 : Basic Instructions Section 2 : Enveloping Section 3 : Charts for Situational Rules Any questions? Contact MCS/JAA representatives dl-mcsit@anthem.com Contact E-Solutions LiveChat and Health Insurance Company are independent licensees ANTHEM is a Page 1 of 14

2 Section 1 - Basic Instructions 1.1 X12 and HIPAA Compliance Checking, and Business Edits EDI interchanges submitted from Anthem Blue Cross (Anthem) for processing pass through compliance edits. In response to the outbound , trading partners must return a 999 in the submitter s trading partner mailbox for acknowledgment. 1.2 HIPAA Compliant s Use HIPAA-compliant codes from current versions of the following: Physician s Current Procedure Terminology (CPT) Health Care Financing Administration Common Procedural Coding System (HCPCS) International Classification of Diseases Clinical Mod (ICD-10-CM) Diseases National Uniform Billing Committee (NUBC) s Diagnosis Related Group (DRG) Number Provider Taxonomy s National Drug s 1.3 Diagnosis s According to the 837I TR3, a transaction is not X12 compliant if decimal points are used in diagnosis codes. Therefore, Anthem will not send diagnosis codes containing a decimal point. 1.4 Uppercase Letters, Special Characters, and Delimiters As specified in the TR3, the basic character set includes uppercase letters, digits, space, and other special characters. All alpha characters must be submitted in UPPERCASE letters only. To avoid syntax errors, hyphens, parentheses and spaces are not used in values for identifiers. Examples: Zip Medical Record # Anthem will not use the following special characters: asterisk (*), less than/greater than signs (<, >), colon (:), and slash (/). This minimizes the risk for a special character to be recognized as a delimiter. Example: Patient Control Number 12* Although an asterisk (*) is a valid special character, it adversely affects processing since it is also a common delimiter. The value 12* may process incorrectly as two separate values 12 and Decimal R Data Element Types R data element types contain a decimal point; involving monetary amounts, units, visits, weights, and frequency. Anthem will use decimal points for monetary amounts, and whole numbers for other types of R data elements. Except for monetary amounts, if R data element type includes a decimal and numbers after the decimal, Anthem adjudicates the claim based on the whole number. Numbers after the decimal will not be considered. and Health Insurance Company are independent licensees ANTHEM is a Page 2 of 14

3 1.6 Numeric s, Monetary Amounts and Units Anthem pays all claims in US dollars and therefore, accepts monetary amounts in US dollars only. s related to foreign currencies will not be used. No negative service line charge or negative units will be used in SVC segment. SV203 Monetary Amount Line Item Charge Amount SV205 Quantity Service Unit Count Section 2 - Enveloping EDI envelopes control and track communications between you and Anthem. One envelope may contain many transaction sets grouped into the following: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) Envelope Specific from Anthem Blue Cross (TR3, Appendix C) ISA Interchange Control Header GS Functional Group Header GE Functional Group Trailer IEA Interchange Control Trailer ISA01 00 GS01 HC GE01 refer to TR3 IEA01 refer to TR3 ISA02 10 spaces GS02 PRBCCA GE02 refer to TR3 IEA02 refer to TR3 ISA03 00 PSBCCA ISA04 10 spaces GS03 RECEIVER ID ISA05 ZZ GS04 refer to TR3 ISA06 PRBCCA GS05 refer to TR3 PSBCCA GS06 refer to TR3 ISA07 ZZ GS07 X ISA08 RECEIVER ID GS08 ISA09 refer to TR3 ISA10 refer to TR3 ISA11 ^ (5E) ISA ISA13 refer to TR3 NOTE. ISA14 refer to TR3 ISA15 refer to TR3 ISA16 refer to TR3 ISA06/GS02 =PRBCCA represents JAA ISA06/GS02=PSBCCA represents PRICE ONLY / FFE and Health Insurance Company are independent licensees ANTHEM is a Page 3 of 14

4 Section 3 - Charts for Situational Rules Listed below are loops, segments, and data elements required for proper adjudication by Anthem per the situational rules in the 837I TR3. P.67 ST Transaction Set Header P.68 BHT Beginning of Hierarchical Trx Loop ID 1000A Submitter Name P.71 NM1 Submitter Name ST03 Implementation Convention Ref BHT06 Transaction Type NM103 Last Name or Organization Name NM109 Identification P.73 PER PER02 Submitter EDI Name Contact PER03 Information Comm No.Qualifier PER04 Comm Number Loop ID 1000B Receiver Name P.76 NM1 NM103 Receiver Name Last Name or CH WGS20 (Submitter Identifier) PROGRAMMER ON CALL TE (Receiver Name) Organization Name NM109 Identification Loop ID 2000A Billing Provider Hierarchical Level P.78 HL Billing Provider Hierarchical Level - Refer to TR3 P.80 PRV PRV01 BI Billing Provider Provider Specialty Information PRV03 Ref Identification Loop ID 2010AA Billing Provider Name P.84 NM1 Billing Provider NM101 Entity ID Name NM109 Identification P.87 N3 N301, N302 Billing Provider Address Address Information - Health Care Claim, Institutional CH - Chargeable Represents Anthem Blue Cross as submitter. Identifies ETIN established by Trading Partner Agreement. Submitter Contact Name TE - Telephone Communication Number Represents Name of MCS Client Represents the Receiver Primary Identification Number. (Provider Taxonomy ) BI - Billing Taxonomy code that applies to the service Billing Provider (Billing Prov Identifier) (Billing Prov Address Line) NPI ('XX') for Non-Exempt providers For paper claims, the P.O. Box may be used, if applicable. and Health Insurance Company are independent licensees ANTHEM is a Page 4 of 14

5 Loop ID 2010A Billing Provider Name (cont d) P.88 N4 Billing Provider City, State, ZIP N403 Postal (Billing Provider's ZIP ) P.90 REF Billing Provider Tax Identification - Refer to TR3 P.91 PER PER02 (Billing Prov Billing Provider Name Contact Name) Contact PER03 TE Information Comm No.Qualifier PER04 (Comm. Comm Number Number) Loop ID 2000B Subscriber Hierarchical Level P.107 HL Subscriber Hierarchical Level - Refer to TR3 P.109 SBR SBR01 Subscriber Payer Resp Information Seq No. SBR03 (Group Number) Group Number Loop ID 2010BA Subscriber Name P.112 NM1 NM102 Subscriber Name Entity Type Qual. NM108 MI ID Qualifier NM109 Identification P.115 N3 Subscriber Address - Refer to TR3 P.116 N4 Subscriber City, State, ZIP - Refer to TR3 P.118 DMG Subscriber Demographic Information - Refer to TR3 P.120 REF Subscriber Secondary Identification - Refer to TR3 P.121 REF Property and Casualty Claim Number - Refer to TR3 Loop ID 2010BB Payer Name P.122 NM1 Payer Name NM103 Payer Name NM108 ID Qualifier NM109 Identification Billing Provider ZIP code will be used as the practicing ZIP code. Contact Name for Billing Provider TE - Telephone Phone Number for Billing Provider Contact P, S, T Usage of 'S' or 'T' accompanies information populated in Loop 2320 and 2330 for COB adjudication information Individual Anthem Blue Cross assigned number Format 10 position alphanumeric MI - Member Identification Number Subscriber ID bytes Recommended to have software support 20 bytes. WGS20 PI (Payer Primary Identifier) P.124 N3 Payer Address - Refer to TR3 P.125 N4 Payer City, State, ZIP - Refer to TR3 P.127 REF Payer Secondary Identification - Refer to TR3 P.129 REF Billing Provider Secondary Identification - Refer to TR3 Loop ID 2000C Patient Hierarchical Level P.131 HL Patient Hierarchical Level - Refer to TR3 Represents Anthem Blue Cross as payer. PI - Payer Identification represents Anthem Blue Cross and Health Insurance Company are independent licensees ANTHEM is a Page 5 of 14

6 Loop ID 2300 Claim Information P.143 CLM Claim Information CLM01 Clm Submitter's Identifier CLM02 Monetary Amount P.149 DTP Discharge Hour - Refer to TR3 P.150 DTP DTP03 Statement Dates Date Time Period P.151 DTP Admission Date/Hour DTP01 Date/Time Qualifier DTP03 Date/Time Period (Patient Control Number) (Total Claim Charge Amt) (Statement From / To Date) P.152 DTP Date-Repricer Received Date - Refer to TR3 P.153 CL1 CL103 Inst Claim Patient Status Admission (Admission Date and Hour) P.154 PWK Claim Supplemental Information - Refer to TR3 P.158 CN1 Contract Information - Refer to TR3 P.160 AMT Patient Estimated Amount Due - Refer to TR3 P.161 REF Service Authorization Exception - Refer to TR3 P.163 REF Referral Number - Refer to TR3 P.164 REF Prior REF01 Ref ID Qualifier G1 Authorization REF02 (Prior Auth Ref Identification Number) P.166 REF REF01 F8 Payer Claim Ref ID Qualifier Control Number REF02 (Payer Claim Ref Identification Control No.) P.167 REF Repriced Claim Number - Refer to TR3 P.168 REF Adjusted Repriced Claim Number - Refer to TR3 P.169 REF Investigational Device Exemption Number - Refer to TR3 Maximum of 20 alphanumeric characters. equals the total amount of submitted charges for service lines in Loop 2400 SV203. Valid medical codes will be based on the "Statement From Date" For claims received without a patient status, the code '99'-Undefined Patient Status will be populated (per Source 239: Patient Status /UB04). G1 - Prior Authorization Number For Entertainment Guilds, this represents the HIN Network Referral Number. F8 - Original Reference Number Represents the claim number assigned by Anthem Blue Cross. P.170 REF REF01 D9 D9 - Claim Number Claim ID for Ref ID Qualifier Transmission Intermediaries REF02 Ref Identification (VAN Trace No.) Represents Anthem s Document Claim Number (DCN). P.172 REF Auto Accident State - Refer to TR3 P.173 REF Medical Record REF01 Ref ID Qualifier EA EA - Medical Record Identification Number Number REF02 Ref Identification (Medical Record Number) P.174 REF Demonstration Project Identifier - Refer to TR3 P.175 REF PRO Approval Number - Refer to TR3 and Health Insurance Company are independent licensees ANTHEM is a Page 6 of 14

7 Loop ID 2300 Claim Information (cont'd) P.176 K3 File Information - Refer to TR3 NTE Segment applies to BlueCard MCS/JAA ONLY P.178 NTE Claim Note NTE01 Note Ref NTE02 Claim Note Text ADD Additional Information Provides the Secondary Payer Pricing Qualifier (SPPQ), Medicare Payer Pricing Qualifier (MPPQ), HOST/HOME status (TPA), Claim Receipt Date, and 835 File Response Indicator. Bytes 1-19: SPPQ information, if applicable DISCOUNT VALID ITS-HOST-PAYS-PRVDR 835=Y~ DISCOUNT NOT VALID ITS-HOST-PAYS-PRVDR 835=Y~ DISCNT CONDITIOINAL ITS-HOST-PAYS-PRVDR 835=Y~ Byte 20: MPPQ information MEDICARE PAYER PRICING QUALIFIER CODE - ASSIGNED 1-Lines w/ Med Allowed Amt, Prov accepts Med Allowed Amt Lines w/o Med Allowed Amt, Prov accepts Host Allowed Amt 2-Lines w/ Med Allowed Amt, Prov accepts Med Allowed Amt Lines w/o Med Allowed Amt, Prov accepts the Charge Amt 3-Lines w/ Med Allowed Amt, Prov accepts lesser of Host or Med Allowed Amt Lines w/o Med Allowed Amt, Prov accepts Host Allowed Amt 4-Lines w/ Med Allowed Amt, Prov accepts lesser of Host or Med Allowed Amt Lines w/o Med Allowed Amt, Prov accepts the Charge Amt ITS-HOST-PAYS-PRVDR 835=Y~ ITS-HOST-PAYS-PRVDR 835=Y~ ITS-HOST-PAYS-PRVDR 835=Y~ ITS-HOST-PAYS-PRVDR 835=Y~ Bytes 21-28: Date Claim Received ITS-HOST-PAYS-PRVDR 835=Y~ Bytes 29-46: Pay to Subscriber/Provider, HOME represents you, the client ITS-HOST-PAYS-PRVDR 835=Y~ ITS-HOME-PAYS-SUB 835=Y~ ITS-HOME-PAYS-PRVDR 835=Y~ For Anthem reject claims, this will contain ANTHEM-REJECT-CLAIM ANTHEM-REJECT-CLAIM 835=Y~ For claims that require payment to the subscriber, Anthem will price the claim and forward to the client to handle direct. Payment must be handled by the client to the subscriber directly. Bytes 50-54: Yes/No indicator if 835 response required for PAR and ECRP ITS-HOST-PAYS-PRVDR 835=Y~ For CO, NV, and CA claims under Bluecard or JAA process, all the claims must be paid by Anthem. This means that all par and non-par providers will require an 835 back to Anthem to issue payment to providers directly. Claims that are rejected by Anthem will not be returned on the 835 by the client, therefore, this flag will be sent as 835=N. and Health Insurance Company are independent licensees ANTHEM is a Page 7 of 14

8 Loop ID 2300 Claim Information (cont'd) NTE Segment applies to BlueCard MCS/JAA ONLY Bytes 56-57: State Indicator CA = California BC = BlueCard IP = Intraplan ITS-HOST-PAYS-PRVDR 835=Y CA~ ITS-HOST-PAYS-PRVDR 835=Y BC~ ITS-HOST-PAYS-PRVDR 835=Y IP~ Bytes 60-61: MRU Decision ITS-HOST-PAYS-PRVDR 835=Y CA CS~ Common MRU decision codes are listed below: AN - Adjudicate Normally CS - Deny - Cosmetic treatment DE - Handle as Dental DM - ERISA: 2nd request for records IC - Handle as Incidental services IN - Handle per infertility treatment exclusion IR - Incomplete route IV - Deny - Investigational treatment MD - Need medical records MR - Misroute NC - Not a covered benefit NO - Need operative report NP - Non-eligible provider PE - Pre-existing condition (PE) PI - Process manually per instructions Bytes 62-63: Claim Source ITS-HOST-PAYS-PRVDR 835=Y CA PC~ Will capture the source of the claim as stored in WGS. Some of the applicable source codes listed below. PC EDI Claims SC Paper Claims. DC DDC Keyed Claim GA GA Large Group Conversion GT Paper Via EDI OC OCR-DDC Byte 64: Limited Provider Flag ITS-HOST-PAYS-PRVDR 835=Y CA PCL~ Will contain L as indication of a provider which is considered a limited provider by Anthem in the location where the services were rendered. Bytes 65-70: Anthem s Reject Action ITS-HOST-PAYS-PRVDR 835=Y CA PC R12345~ Will contain the 6 digit reject action code taken by Anthem on the claim. Applies to claims rejected by Anthem prior to transmission to the client Byte 71: Prompt Pay Indicator ITS-HOST-PAYS-PRVDR 835=Y CA PC Y~ Will contain value of Y as indication of a provider which has prompt payment requirements stipulated as part of their contracts and requires claims to be processed under a certain timeframe to prevent interest from applying. and Health Insurance Company are independent licensees ANTHEM is a Page 8 of 14

9 Loop ID 2300 Claim Information (cont'd) P.180 NTE Billing Note - Refer to TR3 P.181 CRC EPSDT Referral - Refer to TR3 P.184 HI Principal Diagnosis Information - Refer to TR3 P.187 HI Admitting Diagnosis - Refer to TR3 P.189 HI Patient's Reason for Visit - Refer to TR3 P.193 HI External Cause of Injury - Refer to TR3 P.218 HI DRG Information - Refer to TR3 P.220 HI Other Diagnosis Information - Refer to TR3 P.239 HI Principal Procedure Information - Refer to TR3 P.242 HI Other Procedure Information - Refer to TR3 P.258 HI Occurrence Span Information - Refer to TR3 P.271 HI Occurrence Information - Refer to TR3 P.284 HI Information - Refer to TR3 P.294 HI Condition Information - Refer to TR3 P.304 HI Treatment Information - Refer to TR3 P.313 HCP HCP01 Claim Pricing Pricing/ Methodology Repricing Information HCP03 Monetary Amount HCP NON-PAR providers 01 - PAR provider with No allowable-full Discount 03 - NON-PAR provider with agreement (eg. PPO Advantage, PPO Select) 05 NCN (National Care Network priced) 10 - Other Pricing (PAR Provider priced) (Repriced Savings Amt) (SF message codes) Populated when savings realized for par-providers. SF message codes will be populated on ITS Home claims when received See example below: SF Message code P302 and U250 received from ITS: HCP*10*146.51**P302-U250~ HCP12 Represents the approved service units or inpatient days. Quantity HCP13 Reject Reas T1 T1 NONPAR - Cannot identify Provider as TPO (Third Party Organization) Participant HCP14 Policy Compl Procedure Followed (Compliance)/Tier 1 Hospital Loop ID 2310A Attending Physician Name P.319 NM1 NM Attending Provider Attending Entity ID Provider NM109 (Rendering NPI ('XX') for Non-Exempt providers Name Identification Primary ID) P.322 PRV Attending Phys Specialty Info PRV03 Reference Identification (Provider Taxonomy ) Enter the taxonomy code to uniquely identify the provider. P.324 REF Attending Provider Secondary Identification - Refer to TR3 and Health Insurance Company are independent licensees ANTHEM is a Page 9 of 14

10 Loop ID 2310B Operating Physician Name P.326 NM1 Operating Physician Name - Refer to TR3 P.329 REF Operating Physician Secondary Identification - Refer to TR3 Loop ID 2310C Other Operating Physician Name P.331 NM1 Other Operating Physician Name - Refer to TR3 P.334 REF Other Operating Physician Secondary Identification - Refer to TR3 Loop ID 2310D Rendering Provider Name P.336 NM1 Rendering Provider Name - Refer to TR3 P.339 REF Rendering Provider Secondary Identification - Refer to TR3 Loop ID 2310E Service Facility Location Name P.341 NM1 NM Service Location Service Facility Location Name Entity ID NM109 Identification (Service Fac Loc Primary ID) NPI ('XX') for Non-Exempt providers P.344 N3 Service Facility Location Address - Refer to TR3 P.345 N4 Serv Fac Loc City, State, ZIP - Refer to TR3 P.347 REF Service Facility REF01 Ref ID Qualifier 0B 0B - Provider State License Number Location Secondary Identification REF02 Ref Identification (Service Facility Location Additional ID) Loop ID 2310F Referring Provider Name P.349 NM1 Referring Provider Name - Refer to TR3 P.352 REF Referring Provider Secondary Identification - Refer to TR3 Anthem will forward COB information (excluding Other Payer Address Information) whenever received from submitting provider/source. If data received is incomplete, dummy membership information will be populated solely for the purpose of passing COB amounts to the client. Loop ID 2320 Other Subscriber Information SBR segment created in support of SVD codes due to clinical editing / pricing even with no COB. P.354 SBR Other Subscriber Information SBR01 Payer Resp Sequence No. SBR02 Individual Rel SBR09 Claim Filing Indicator P.358 CAS Claim Level Adjustments - Refer to TR3 P - Primary; S - Secondary; T - Tertiary In support of SVD codes due to clinical editing or pricing, the value will match the payer resp seq code in Loop 2000B SBR In support of SVC and CAS segments due to clinical editing or pricing, 21 will be used CI 21 - Unknown In support of SVC and CAS segments due to clinical editing or pricing, CI will be used CI - Commercial Insurance Co. and Health Insurance Company are independent licensees ANTHEM is a Page 10 of 14

11 Anthem will forward COB information (excluding Other Payer Address Information) whenever received from submitting provider/source. If data received is incomplete, dummy membership information will be populated solely for the purpose of passing COB amounts to the client. Loop ID 2320 Other Subscriber Information (cont'd) P.364 AMT COB Payer Paid Amount AMT01 Amount Qualifier AMT02 Monetary Amount D D - Payer Paid Amount (Payer Paid Represents total amount paid by Other Payer. Amount) P.365 AMT Remaining Patient Liability - Refer to TR3 P.366 AMT COB Total Non-Covered Amount - Refer to TR3 P.367 OI Oth Insurance Coverage Information OI03 Yes/No Condition or Response Represents assignment of benefits indicator. N - No; Y - Yes OI06 Release of Information In support of SVC and CAS segments due to clinical editing or pricing, Y will be used. Y - Yes, Provider has signed statement permitting release of medical billing data related to a claim P.369 MIA Inpatient Adjudication Information - Refer to TR3 P.374 MOA Outpatient Adjudication Information - Refer to TR3 Loop ID 2330A Other Subscriber Name P.377 NM1 Other Subscriber Name NM103 Name Last or Organization Name NM108 ID Qualifier NM109 Identification P.380 N3 Other Subscriber Address - Refer to TR3 P.381 N4 Other Subscriber City, State, ZIP - Refer to TR3 P.383 REF Other Subscriber Secondary Identification - Refer to TR3 Loop ID 2330B Other Payer Name P.384 NM1 Other Payer Name - Refer to TR3 P.386 N3 Other Payer Address - Refer to TR3 P.387 N4 Other Payer City, State, ZIP - Refer to TR3 P.389 DTP Claim Check or Remittance Date DTP01 Date/Time Qualifier DTP03 Date Time Period Information from other carrier will be passed (exception: in support of SVC & CAS segments due to clinical editing or pricing, REQ FOR ANTHEM SVD will be used). MI - Member Identification No.; ZZ - Mutually Defined Information from other carrier will be passed (exception: in support of SVC & CAS segments due to clinical editing or pricing, MI will be used). Information from other carrier will be passed (exception: in support of SVC & CAS segments due to clinical editing or pricing, 00 will be used) Date Claim Paid (Adjud. or Payment Date) Represents date the primary payer adjudicated the claim. and Health Insurance Company are independent licensees ANTHEM is a Page 11 of 14

12 Loop ID 2330B Other Payer Name (cont d) P.390 REF Other Payer Secondary Identifier - Refer to TR3 P.392 REF Other Payer Prior Authorization Number - Refer to TR3 P.393 REF Other Payer Referral Number - Refer to TR3 P.394 REF Other Payer Claim Adjustment Indicator - Refer to TR3 P.395 REF Other Payer Claim Control Number - Refer to TR3 Loop ID 2330C Other Payer Attending Provider P.396 NM1 Other Payer Attending Provider - Refer to TR3 P.398 REF Other Payer Attending Provider Secondary Identification - Refer to TR3 Loop ID 2330D Other Payer Operating Physician P.400 NM1 Other Payer Operating Physician - Refer to TR3 P.402 REF Other Payer Operating Physician Secondary Identification - Refer to TR3 Loop ID 2330E Other Payer Other Operating Physician P.404 NM1 Other Payer Other Operating Physician - Refer to TR3 P.406 REF Other Payer Other Operating Physician Secondary Identification - Refer to TR3 Loop ID 2330F Other Payer Service Facility Location P.408 NM1 Other Payer Service Facility Location - Refer to TR3 P.410 REF Other Payer Service Facility Location Secondary Identification - Refer to TR3 Loop ID 2330G Other Payer Rendering Provider Name P.412 NM1 Other Payer Rendering Provider Name - Refer to TR3 P.414 REF Other Payer Rendering Provider Secondary Identification - Refer to TR3 Loop ID 2330H Other Payer Referring Provider P.416 NM1 Other Payer Referring Provider - Refer to TR3 P.418 REF Other Payer Referring Provider Secondary Identification - Refer to TR3 Loop ID 2330I Other Payer Billing Provider P.420 NM1 Other Payer Billing Provider - Refer to TR3 P.422 REF Other Payer Billing Provider Secondary Identification - Refer to TR3 Loop ID 2400 Service Line Number P.423 LX Service Line Number - Refer to TR3 P.424 SV2 Institutional Service SV202-1 Product/Service ID Qualifier SV203 Monetary Amount HC (Line Item Charge Amount) P.429 PWK Line Supplemental Information - Refer to TR3 P.433 DTP Service Date DTP03 Date Time (Service Date) P.435 REF Line Item Control Number Period REF02 Reference Identification (Line Item Control Number) P.437 REF Repriced Line Item Reference Number - Refer to TR3 P.438 REF Adjusted Repriced Line Item Reference Number - Refer to TR3 P.439 AMT Service Tax Amount - Refer to TR3 HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) s Sum of service line charges must equal the Total Claim Charge Amount in Loop 2300 CLM02. and Health Insurance Company are independent licensees ANTHEM is a Page 12 of 14

13 837I Health Care Claim Companion Document Outbound Loop ID 2400 Service Line Number (cont d) P.440 AMT Facility Tax Amount - Refer to TR3 P.441 NTE Third Party Organization Notes - Refer to TR3 P.442 HCP Service lines with HCP segment are required to be returned on 835. Claim Pricing/ Repricing Information HCP01 Pricing Methodology 00 - NON-PAR provider priced 01 - PAR provider with No allowable-full Discount 03 - NON-PAR provider pricing with agreement (eg. PPO Advantage, PPO Select) 05 NCN (National Care Network priced) 10 - PAR Provider priced HCP03 Represents savings amount to consider on a detail line. Monetary Amount HCP12 Represents the approved service units or inpatient days. Quantity HCP13 Reject Reas T1 T1 - Cannot identify Provider as TPO (Third Party Organization) Participant HCP Procedure Followed (Compliance)/Tier 1 Hospital Policy Compl Loop ID 2410 Drug Identification P.449 LIN Drug Identification - Refer to TR3 P.452 CTP Drug Quantity - Refer to TR3 P.454 REF Prescription of Compound Drug Association Number - Refer to TR3 Loop ID 2420A Operating Physician Name P.456 NM1 Operating Physician Name - Refer to TR3 P.459 REF Operating Physician Secondary Identification - Refer to TR3 Loop ID 2420B Other Operating Physician Name P.461 NM1 Other Operating Physician Name - Refer to TR3 P.464 REF Other Operating Physician Secondary Identification - Refer to TR3 Loop ID 2420C Rendering Provider Name P.466 NM1 Rendering Provider Name - Refer to TR3 P.469 REF Rendering Provider Secondary Identification - Refer to TR3 Loop ID 2420D Referring Provider Name P.471 NM1 Referring Provider Name - Refer to TR3 P.474 REF Referring Provider Secondary Identification - Refer to TR3 Loop ID 2430 Line Adjudication Information Multiple Adjustments will be sent as they apply on COB and Medicare claims. It will also be used to notify the receiver of denials or limitations found by our editing or pricing. P.476 SVD Line Adjudication Information SVD01 Identification SVD02 Monetary Amount SVD06 Assigned Number (Other Payer Primary Identifier) (Service Line Paid Amount) (Line Number) Matches Loop 2330B NM109 identifying Other Payer. Amount paid for this service line by COB/Medicare prior payer. Bundled Line Number (will Be used ONLY for Claims Xten) and Health Insurance Company are independent licensees ANTHEM is a Page 13 of 14

14 Loop ID 2430 Line Adjudication Information (cont d) CAS Segment s (refer to TR3) received on electronic transactions will be passed as received. CAS Segment s listed below will be applied to paper claims. P.480 CAS Line Adjustment CAS01 Adj Group Anthem Adjustments made by Anthem PI COB DEDUCTIBLE AMOUNT PR 1 COINSURANCE AMOUNT PR 2 COPAYMENT AMOUNT PR 3 NON-ELIGIBLE AMOUNT CO 96 DISCOUNT AMOUNT CO 45 CONTRACT EXCLUSION + CONTRACT LIMITATION OA 96 Medicare DEDUCTIBLE AMOUNT PR 1 Part A/B COINSURANCE AMOUNT PR 2 COPAYMENT AMOUNT PR 3 NON-ELIGIBLE AMOUNT CO 45 CONTRACT EXCLUSION OA 96 P.486 DTP Line Check or Remittance Date - Refer to TR3 P.487 AMT Remaining Patient Liability - Refer to TR3 P.488 SE Transaction Set Trailer - Refer to TR3 CAS02 Adj Reason and Health Insurance Company are independent licensees ANTHEM is a Page 14 of 14