Vendor Specifications 837 Institutional Claim ASC X12N Version X223A2. for. State of Idaho MMIS

Transcription

1 Vendor Specifications 837 Institutional Claim ASC X12N Version X223A2 for State of Idaho MMIS Date of Publication: 6/16/2016 Document Number: TL426 Version: 8.0

2 Revision History Version Date Author Action/Summary of Changes /01/2011 Molina Initial document /21/2011 Eric Harvey Added the HI01-1 and HI02-2 segments in loop /05/2012 TQD Promoted to next whole version /18/2012 Alisa Nicolls Updated the 2010BA loop NM109 segment with approved language per 10 digit M /19/2012 TQD Promoted to the next whole version /22/2014 M McFadden Added ICD-10 references Reviewed and brought up to current standards /31/2014 M McFadden Edifecs 8.3 Upgrade (CCF 10735B1) changes 3.3 8/7/2014 Megan Lloyd Updated the document based on Cindy Day s feedback related to CCF 10735B /15/2014 TQD DHW validated 8/15/ /20/2014 M McFadden Corrected value for PRV /24/2014 TQD DHW validated 9/23/ /21/2015 M McFadden Semi-annual review performed made changes 6.0 6/8/2015 TQD DHW validated 6/5/ /15/2015 Cathy Butler Semi-annual changes 7.0 1/25/2016 TQD DHW validated changes 1/22/ /26/2016 Douglas Semi-annual review changes made Greer 8.0 6/16/2016 TQD DHW validated changes 6/10/16 Last Updated: 6/16/2016 Page ii

3 DISCLAIMER The Molina Healthcare Companion Guide for Idaho is subject to change at the instruction of the Department. Therefore, it is the responsibility of the trading partner to ensure that the latest version of this guide is used when designing/ building X12N 5010 EDI transactions. The trading partner should frequently check for updates to the companion guide. Molina Healthcare accepts no liability for any costs that the trading partner may incur that arise from or are related to changes to the companion guide. Last Updated: 6/16/2016 Page iii

4 Table of Contents 1. Companion Guide Purpose Required Information Trading Partner Delimiters Additional Information Institutional Claim... 3 Appendix A Table of Figures Figure 2-1: 837 Institutional Claim... 3 Last Updated: 6/16/2016 Page iv

5 1. Companion Guide Purpose This companion guide documents the transaction type listed below and further defines situational and required data elements that are used for processing claims for programs administered by the Idaho Medicaid. This document is not the complete EDI transaction format specifications. Please refer to the 5010A2 Technical Report Type 3 for information not supplied in this document, such as code lists, definitions, and edits. Health Care Claim: Institutional X223 May 2006 Health Care Claim: Institutional X223A1 October 2007 Health Care Claim: Institutional X223A2 June 2010 For any questions or to begin testing, please contact the Molina EDI Helpdesk at 1 (866) and ask for Technical Support or Molina at idedisupport@molinahealthcare.com Required Information Data elements, segments, and loops not included in this guide are not used for processing claims by Idaho Medicaid, but must still be sent if the information is required for compliance with the ASC X12N version 5010A2 format Trading Partner A trading partner is defined as any entity with which Molina exchanges electronic data. The term electronic data is not limited to HIPAA X12 transactions. Idaho Medicaid s Health PAS system supports the following categories of trading partner: Provider Billing Agency Clearinghouse Health Plan Molina will assign trading partner s to support the exchange of X12 EDI transactions for providers, billing agencies and clearinghouses, and other health plans. All trading partners must be authorized to submit production EDI transactions. Any trading partner may submit test EDI transactions. Trading partners must have a T in ISA15 in all submitted test files. Authorization is granted on a per transaction basis. For example, a trading partner may be certified to submit 837P professional claims but not certified to submit 837I institutional claim files. Trading partners must submit three test files of a particular transaction type, with a minimum of 15 transactions within each file, and have no failures or rejections in order to become certified for production. Users will be notified via and the Trading Partner Status page of Health PAS-Online when testing for a particular transaction has been completed. Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may be found in Appendix A of this document. To obtain a trading partner, please visit the website at or contact Molina at 1 (866) , and choose option 2. Last Updated: 6/16/2016 Page 1 of 42

6 1.3. Delimiters Idaho Medicaid does not require the use of specific values for the delimiters used in electronic transactions. The suggested values are included in the specifications below Additional Information Please refer to the industry 5010A2 Technical Report Type 3 (also known as the TR3 Guide) for information not supplied in this document, such as code lists, definitions, and edits. Last Updated: 6/16/2016 Page 2 of 42

7 Institutional Claim Figure 2-1: 837 Institutional Claim Name/ Data 3 R ISA HEADER ISA Interchange Control Header ISA01 Authorization 2 I01 R 00 Information ISA02 Authorization AN 10 I02 R Space fill Information ISA03 Security Information 2 I03 R 00 ISA04 Security Information AN 10 I04 R Space fill ISA05 Interchange 2 I05 R ZZ ISA06 Interchange Sender AN 15 I06 R Molina assigned trading partner + 3 spaces. i.e. TP spaces ISA07 Interchange 2 I05 R ZZ ISA08 Interchange Receiver AN 15 I07 R _MMIS_4MOLINA ISA09 Interchange Date DT 6 I08 R YYMMDD ISA10 Interchange Time TM 4 I09 R HHMM Last Updated: 6/16/2016 Page 3 of 42

8 Name/ Data ISA11 Interchange Control 1 I10 R ^ ISA12 Interchange Version 5 I11 R Number ISA13 Interchange Control Number N0 9 I12 R Must be identical to the interchange trailer IEA02 (defined by sending Trading Partner) ISA14 Ack. Requested 1 I13 R 1 (Interchange acknowledgement requested) ISA15 Usage Indicator 1 I14 R P or T (Must contain a P indicator in production) ISA16 1 I15 R : GS Functional Group 2 R GS Header GS01 Functional Identifier R HC Code GS02 Application Sender's Code AN 2/ R Molina assigned trading partner GS03 Application Receiver's Code AN R _MMIS_4MOLINA Last Updated: 6/16/2016 Page 4 of 42

9 Name/ Data GS04 Date DT R CCYYMMDD GS05 Time TM 4/8 337 R HHMM GS06 Group Control Number N0 1/9 28 R Assigned by Sender GS07 Responsible Agency 1/2 455 R X Code GS08 Version / Release Code AN R X223A2 ST Transaction Set Header 2 R ST ST01 Transaction Set R 837 Identifier Code ST02 Transaction Set Control Number AN 4/9 329 R Sequential number assigned by sender ST and SE must be equivalent ST03 Technical Report Type 3 AN 35 R X223A2 Version Name BHT Beginning Hierarchical 3 R BHT Transaction BHT01 Hierarchical Structure R 0019 Code BHT02 Transaction Set Purpose R 00 Original Code BHT03 Reference identification AN 1/ R Submitter Transaction Last Updated: 6/16/2016 Page 5 of 42

10 Name/ Data Identifier BHT04 Date DT R CCYYMMDD BHT05 Time TM 4/8 337 R HHMM BHT06 Transaction Type Code R CH = Chargeable RP = Reporting (used for encounters) 1000A NM1 Submitter Name 3 R NM1 NM101 Entity Identifier Code 2/3 98 R 41 NM102 Entity Type R 1 or 2 NM103 Name Last or AN 1/ R Organization Name NM104 Name First AN 1/ S NM105 Name Middle AN S NM108 Identification Code 1/2 66 R 46 NM109 Identification Code AN 2/80 67 R Trading Partner 1000A PER Submitter EDI Contact 3 R PER Information PER01 Contact Function Code 2/2 366 R IC Last Updated: 6/16/2016 Page 6 of 42

11 Name/ Data PER02 Name AN 1/60 93 R PER03 Communication Number 2/2 365 R TE = Telephone PER04 Communication Number AN 1/ R 1000B NM1 Receiver Name 3 R NM1 NM101 Entity Identifier Code 2/3 98 R 40 NM102 Entity Type R 2 NM103 Name Last or AN R _MMIS_4MOLINA Organization Name NM108 Identification Code 1/2 66 R 46 NM109 Identification Code AN R _MMIS_4MOLINA 2000A HL Billing/Pay-to Provider 2 R HL Hierarchical Level HL01 Hierarchical Number AN R 1 HL03 Hierarchical Level Code 1/2 735 R 20 HL04 Hierarchical Child Code 1/1 736 R A PRV Billing/Pay-to Provider Specialty Information 3 S PRV Last Updated: 6/16/2016 Page 7 of 42

12 Name/ Data PRV01 Provider Code 1/ R BI = Billing PRV02 Reference Identification 2/3 128 R PXC PRV03 Reference Identification AN 1/ R Provider Taxonomy Code 2010AA NM1 Billing Provider Name 3 R NM1 NM101 Entity Identifier Code 2/3 98 R 85 NM102 Entity Type R 2 NM103 Name Last or AN 1/ R Organization Name NM108 Identification Code 1/2 66 S XX = National Provider (NPI) NM109 Identification Code AN 2/80 67 S NPI 2010AA N3 Billing Provider Address 2 R N3 N301 Address Information AN 1/ R N302 Address Information AN 1/ S Required if a second address line exists. Last Updated: 6/16/2016 Page 8 of 42

13 Name/ Data 2010AA N4 Billing Provider 2 R N4 City/State/Zip Code N401 City Name AN 2/30 19 R N402 State or Province Code R N403 Postal Code 5/ R 2010AA REF Billing Provider Secondary Identification Number 3 R REF01 Reference Identification 2/3 128 R EI = Employer s Identification Number REF02 Reference Identification 1/ R 2000B HL Subscriber Hierarchical 2 R HL Level HL01 Hierarchical Number AN R 2 HL02 Hierarchical Parent AN 1/ R Number HL03 Hierarchical Level Code 1/2 735 R 22 HL04 Hierarchical Child Code R B SBR Subscriber Information 3 R SBR Last Updated: 6/16/2016 Page 9 of 42

14 SBR01 Name/ Data Payer Responsibility Sequence Number Code R P, S or T SBR02 Individual Relationship S 18 Code SBR03 Reference Identification AN 1/ S SBR04 Name AN 1/60 93 S SBR09 Claim Filing Indicator 1/ S MC = Medicaid Code 2010BA NM1 Subscriber Name 3 R NM1 NM101 Entity Identifier Code 2/3 98 R IL NM102 Entity Type R 1 = Person NM103 Name Last or AN 1/ R Organization Name NM104 Name First AN 1/ S NM105 Name Middle AN 1/ S NM107 Name Suffix AN 1/ S Last Updated: 6/16/2016 Page 10 of 42

15 NM108 Name/ Data Identification Code 1/2 66 R MI = Member Identification Number NM109 Identification Code AN 7/10 67 R Enter the Idaho Medicaid participant s 10 digit identification number. Always add leading zeroes to make a total of 10 digits if the participant s card reflects 7 digits. 2010BA N3 Subscriber Address 2 R N3 N301 Address Information AN 1/ R N302 Address Information AN 1/ S 2010BA N4 Subscriber 2 R N4 City/State/Zip Code N401 City Name AN 2/30 19 R N402 State or Province Code R N403 Postal Code 5/ R 2010BA DMG Demographic 3 DMG Information DMG01 Date Time Period 2/ D8 Format Last Updated: 6/16/2016 Page 11 of 42

16 Name/ Data DMG02 Date Time Period AN 1/ Date of birth CCYYMMDD DMG03 Gender Code 1/ M=Male F=Female U=Unknown 2010BB NM1 Payer Name 3 R NM1 NM101 Entity Identifier Code 2/3 98 R PR NM102 Entity Type R 2 NM103 Name Last or AN 1/ R _MMIS_4MOLINA Organization NM108 Identification Code 1/2 66 R PI = Payer Identification NM109 Identification Code AN 2/80 67 R _MMIS_4MOLINA REF Billing Provider 3 S REF Secondary Identification REF01 Reference Identification 2/3 R G2 REF02 Reference Identification AN 1/50 R Provider Medicaid (Atypical Providers) Last Updated: 6/16/2016 Page 12 of 42

17 Name/ Data 2300 CLM Claim Information 3 R CLM CLM01 Claim Submitter s Identifier AN (1/20) 1028 R CLM02 Monetary Amount R 1/ R CLM05-1 Facility Code AN 1/ R AN CLM05-2 Facility Code AN 1/ R A AN CLM05-3 Claim Frequency Type R Valid codes are 0 9 Code CLM07 Provider Accept 1/ O Assignment Code CLM08 Yes/No Condition or R Y Response Code CLM09 Release of Information R Y Code Last Updated: 6/16/2016 Page 13 of 42

18 Name/ Data CLM20 Delay Reason Code 1/ S 2300 DTP Discharge Hour 3 S DTP Note: cannot be used if claim is outpatient or claim is inpatient and CLM05-03 is 2 or 3. DTP01 Date/Time R 096 DTP02 Date Time Period 2/ R TM Format DTP03 Date Time Period AN 1/ R HHMM 2300 DTP Statement Dates 3 R DTP DTP01 Date/Time R 434 DTP02 Date Time Period 2/ R RD8 Format DTP03 Date Time Period AN 1/ R CCYYMMDD- CCYYMMDD 2300 DTP Admission Date/Hour 3 S DTP DTP01 Date/Time R 435 Last Updated: 6/16/2016 Page 14 of 42

19 DTP02 Name/ Data Date Time Period Format 2/ R DT DTP03 Date Time Period AN 1/ R CCYYMMDDHHMM 2300 CL1 Institutional Claim Code 3 R CL1 CL101 Priority (Type) of Admission or Visit R CL102 Point of Origin for Admission or Visit S CL103 Patient Status Code 1/ S If = 20, 40, 41 or 42 then 2300\HI Occurrence Information should be used with code 55 in HIxx-02 (date of death) 2300 REF Original Reference 3 S REF Number (ICN/DCN) REF01 Reference Identification 2/3 128 R 9F = Referral REF02 Reference Identification AN 1/ R Original ICN 2300 REF Prior Authorization 3 S REF REF01 Last Updated: 6/16/2016 Page 15 of 42 Reference Identification 2/3 128 R G1 = Prior Authorization Number

20 Name/ Data REF02 Reference Identification AN 1/ R Assigned Prior Authorization Number 2300 REF Referral Number 3 S REF REF01 Reference Identification 2/3 128 R F8 = Original Reference Number REF02 Reference Identification AN 1/ R 2300 REF Medical Record Number 3 S REF REF01 Reference Identification 2/3 128 R EA REF02 Reference Identification AN 1/ R 2300 HI Principal Diagnosis 2 S HI Information HI01-1 Code List Code 1/ R BK (ICD-9) Principal Diagnosis ABK (ICD-10) Principal Diagnosis HI01-2 Industry Code AN 1/ R Principal Diagnosis Code Note: Cannot be External Cause Code AN :::::: s (for not used elements) HI01-9 Present on Admission Last Updated: 6/16/2016 Page 16 of 42

21 Name/ Data Indicator 2300 HI Admitting Diagnosis 2 S HI Information HI01-1 Code List Code 1/ R BJ (ICD-9) Admitting Diagnosis ABJ (ICD-10) Admitting Diagnosis HI01-2 Industry Code AN 1/ R Admitting Diagnosis Code AN :::::: s (for not used elements) HI01-9 Present on Admission Indicator 2300 HI Patient Reason for Visit 2 S HI Diagnosis Information HI01-1 Code List Code 1/ R PR (ICD-9) Patient Reason APR (ICD-10) Patient Reason HI01-2 Industry Code AN 1/ R Patient Reason for Visit Diagnosis Code must be unique within the Claim s (for not AN :::::: Last Updated: 6/16/2016 Page 17 of 42

22 HI01-9 Name/ Data used elements) Present on Admission Indicator Note: Can be up to 3 HI0x-1 thru HI0x-9 elements separated by * 2300 HI External Cause of Injury 2 S HI Diagnosis Information HI01-1 Code List Code 1/ R BN (ICD-9) External Cause of Injury ABN (ICD-10) External Cause of Injury HI01-2 Industry Code AN 1/ R External Cause of Injury Diagnosis Code AN :::::: s (for not used elements) HI01-9 Present on Admission Indicator Note: Can be up to 12 HI0x-1 thru HI0x-9 elements separated by * 2300 HI Other Diagnosis 2 S HI Information HI01-1 Code List Code 1/ R BF (ICD-9) Other Last Updated: 6/16/2016 Page 18 of 42

23 Name/ Data Diagnosis ABF (ICD-10) Other Diagnosis HI01-2 Industry Code AN 1/ R Other Diagnosis Code AN :::::: s (for not used elements) HI01-9 Present on Admission Indicator Note: Can be up to 12 HI0x-1 thru HI0x-9 elements separated by * 2300 HI Principal Procedure 2 S HI Information HI01-1 Code List Code 1/ R BR (ICD-9) Principal Procedure BBR (ICD-10) Principal Procedure HI01-2 Industry Code AN 1/ R Principal Procedure Code HI01-3 Date Time Period 2/ S D8 Format HI01-4 Date Time Period AN 1/ S CCYYMMDD Last Updated: 6/16/2016 Page 19 of 42

24 Name/ Data 2300 HI Other Procedure 2 S HI Information HI01-1 Code List Code 1/ R BQ (ICD-9) Other Procedure BBQ (ICD-10) Other Procedure HI01-2 Industry Code AN 1/ R Other Procedure Code HI01-3 Date Time Period 2/ S D8 Format HI01-4 Date Time Period AN 1/ S CCYYMMDD Note: Can be up to 12 HI0x-1 through HI0x- 4 elements separated by * 2300 HI Occurrence Span 2 S HI Information HI01-1 Code List Code 1/ R BI Occurrence Span HI01-2 Industry Code AN 1/ R Occurrence Span code HI01-3 Date Time Period 2/ S RD8 Last Updated: 6/16/2016 Page 20 of 42

25 Name/ Data Format HI01-4 Date Time Period AN 1/ S CCYYMMDD- CCYYMMDD Note: Can be up to 12 HI0x-1 through HI0x- 4 elements separated by * 2300 HI Occurrence Information 2 S HI HI01-1 Code List Code 1/ R BH Occurrence Code HI01-2 Industry Code AN 1/ R Occurrence Code Note: must be 55 (date of death) when CL103 is one of 20, 40, 41 or 42. HI01-3 Date Time Period 2/ R D8 Format HI01-4 Date Time Period AN 1/ R CCYYMMDD Note: Can be up to 12 HI0x-1 through HI0x- 4 elements separated by * 2300 HI Information Codes 2 S HI Last Updated: 6/16/2016 Page 21 of 42

26 Name/ Data HI01-1 Code List Code 1/ R BE Code HI01-2 Industry Code AN 1/ R Code Note: Can be up to 12 HI0x-1 through HI0x- 2 elements separated by * 2300 HI Condition Information 2 S HI HI01-1 Code List Code 1/ R BG Condition Code HI01-2 Industry Code AN 1/ R Condition Code Note: Can be up to 12 HI0x-1 through HI0x- 2 elements separated by * 2310A NM1 Attending Physician 3 S NM1 Name NM101 Entity Identifier Code 2/3 98 R 71 NM102 Entity Type R 1 Person NM103 Name Last or AN 1/ R Organization Name NM104 Name First AN 1/ S Last Updated: 6/16/2016 Page 22 of 42

27 Name/ Data NM108 Identification Code 1/2 66 S XX = National Provider (NPI) NM109 Identification Code AN 2/80 67 S NPI 2310A PRV Attending Physician 3 S PRV Specialty Information PRV01 Provider Code 1/ R AT PRV02 Reference Identification 2/3 128 R PXC PRV03 Reference Identification AN 1/ R Provider Taxonomy Code 2310A REF Attending Physician 3 S REF Secondary Identification REF01 Reference Identification 2/3 128 R EI = Employer s Identification Number G2= Provider Medicaid REF02 Reference Identification AN 1/ R EIN or Provider Medicaid 2310B NM1 Operating Physician 3 S NM1 Name NM101 Entity Identifier Code 2/3 98 R 72 Last Updated: 6/16/2016 Page 23 of 42

28 Name/ Data NM102 Entity Type R 1 - person NM103 Name Last or AN 1/ R Organization Name NM104 Name First AN 1/ R NM105 Name Middle AN 1/ S NM108 Identification Code AN 2 XX = National Provider (NPI) NM109 Identification Code AN 2/80 R NPI 2310B REF Operating Physician 3 S REF Secondary Identification REF01 Reference Identification 2/3 R G2 = Provider Medicaid REF02 Reference Identification AN 1/ R Provider Medicaid 2310C NM1 Other Operating 3 S NM1 Physician Name NM101 Entity Identifier Code 2/3 98 R ZZ NM102 Entity Type R 1 person NM103 Name Last or AN 1/ R Last Updated: 6/16/2016 Page 24 of 42

29 Name/ Data Organization Name NM104 Name First AN 1/ S NM105 Name Middle AN 1/ S NM108 Identification Code 1/2 66 R XX=National Provider (NPI) NM109 Identification Code AN 2/80 67 R NPI 2310C REF Other Provider 3 S REF Secondary Identification REF01 Reference Identification 2/3 128 R EI = EIN G2 = Provider Medicaid REF02 Reference Identification AN 1/ R EIN or Provider Medicaid 2310E NM1 Service Facility Name 3 S NM1 NM101 Entity Identifier Code 2/3 98 R 77 NM102 Entity Type R 2 NM103 Name Last or Organization Name AN 1/ R Service Location Name Last Updated: 6/16/2016 Page 25 of 42

30 Name/ Data NM108 Identification Code AN ½ 66 S XX=National Provider (NPI) NM109 Identification Code AN 2/80 67 S NPI - do not send if same as for Billing Provider 2310E N3 Service Facility Location Address S N3 N301 Address Information AN 1/ R N302 Address Information AN 1/ S 2310E N4 Service Facility City/State/Zip 2 N4 N401 City AN 2/30 19 R N402 State R N403 Zip Code AN 3/ R 2310E REF Service Facility 3 S REF Secondary Identification REF01 Reference Identification 2/3 128 R LU REF02 Reference Identification AN 1/ R Service Location Identifier ** for Medicare COB Last Updated: 6/16/2016 Page 26 of 42

31 Name/ Data information the following segments are required ** 2320 SBR Other Subscriber 3 S SBR Information SBR01 Payer Responsibility R P Sequence Number Code SBR02 Individual Relationship R 18 Code SBR03 Reference Identification AN 1/ S Insured Group or Policy Number SBR04 Name AN 1/60 93 S MEDICARE SBR09 Claim Filing Indicator 1/ S MA Code 2320 CAS Claim Level 3 S CAS Adjustments CAS01 Claim Adjustment 1/ R PR Group Code CAS02 Claim Adjustment Reason Code 1/ R 1 - for Medicare Deductible CAS03 Monetary Amount R 1/ R Medicare Deductible Last Updated: 6/16/2016 Page 27 of 42

32 Name/ Data Amount CAS04 Quantity R 1/ S CAS05 Claim Adjustment Reason Code 1/ S 2 - Medicare Coinsurance CAS06 Monetary Amount R 1/ S Medicare Coinsurance Amount CAS07 Quantity R 1/ S CAS08 Claim Adjustment Reason Code 1/ S 122 Medicare Psychiatric Reduction CAS09 Monetary Amount R 1/ S Medicare Psychiatric Reduction Amount CAS10 Quantity R 1/ S 2320 AMT Coordination of Benefits 3 S AMT (COB) Allowed Amount AMT01 Amount Code 1/3 522 R D Payer Paid Amt AMT02 Monetary Amount R 1/ R Medicare Paid Amount 2320 OI Other Insurance 2 S OI Coverage Information Last Updated: 6/16/2016 Page 28 of 42

33 OI03 Name/ Data Yes/No Condition or Response Code R Y OI06 Release of Information R Y Code 2330A NM1 Other Subscriber Name 3 S NM1 NM101 Entity Identifier Code 2/3 98 R IL NM102 Entity Type R 1 Person NM103 Name Last or AN 1/ R Organization Name NM104 Name First AN 1/ S NM105 Name Middle AN 1/ S NM108 Identification Code 1/2 66 R MI NM109 Identification Code AN 2/80 67 R Medicare Member 2330B NM1 Other Payer Name 3 S NM1 NM101 Entity Identifier Code 2/3 98 R PR NM102 Entity Type R 2 Last Updated: 6/16/2016 Page 29 of 42

34 Name/ Data NM103 Name Last or AN 1/ R MEDICARE Organization Name NM108 Identification Code 1/2 66 R MI NM109 Identification Code AN 2/80 67 R MC B DTP Claim Adjudication Date 3 S DTP DTP01 Date/Time R 573 DTP02 Date Time Period 2/ R D8 Format DTP03 Date Time Period AN 1/ R Medicare Paid Date CCYYMMDD *** the following segments are for non- Medicare COB information 2320 SBR Other Subscriber 3 S SBR Information SBR01 Payer Responsibility R S Sequence Number Code SBR02 Individual Relationship R 18 Last Updated: 6/16/2016 Page 30 of 42

35 Name/ Data Code SBR03 Reference Identification AN 1/ S Insured Group or Policy Number SBR04 Name AN 1/60 93 S OTHERINS SBR09 Claim Filing Indicator 1/ S ZZ Code 2320 CAS Claim Level 3 S CAS Adjustments CAS01 Claim Adjustment 1/ R PR Group Code CAS02 Claim Adjustment Reason Code 1/ R 1 - Other Insurance Deductible CAS03 Monetary Amount R 1/ R Other Insurance Deductible Amount CAS04 Quantity R 1/ S CAS05 Claim Adjustment Reason Code 1/ S 2 - Other Insurance Coinsurance CAS06 Monetary Amount R 1/ S Other Insurance Coinsurance Amount Last Updated: 6/16/2016 Page 31 of 42

36 Name/ Data CAS07 Quantity R 1/ S 2320 AMT Coordination of Benefits 3 S AMT (COB) Allowed Amount AMT01 Amount Code 1/3 522 R D Other Insurance Paid AMT02 Monetary Amount R 1/ R Other Insurance Paid Amount 2320 OI Other Insurance 2 S OI Coverage Information OI03 Yes/No Condition or R Y Response Code OI06 Release of Information R Y Code 2330A NM1 Other Subscriber Name 3 S NM1 NM101 Entity Identifier Code 2/3 98 R IL NM102 Entity Type R 1 NM103 Name Last or Organization Name AN 1/ R Other Insurance Organization Name NM104 Name First AN 1/ S Last Updated: 6/16/2016 Page 32 of 42

37 Name/ Data NM105 Name Middle AN 1/ S NM108 Identification Code 1/2 66 R MI NM109 Identification Code AN 2/80 67 R Other Insurance Member Id 2330B NM1 Other Payer Name 3 S NM1 NM101 Entity Identifier Code 2/3 98 R PR NM102 Entity Type R 2 NM103 Name Last or AN 1/ R OTHERINS Organization Name NM108 Identification Code 1/2 66 R PI NM109 Identification Code AN 2/80 67 R OT B DTP Claim Adjudication Date 3 S DTP DTP01 Date/Time R 573 Last Updated: 6/16/2016 Page 33 of 42

38 DTP02 Name/ Data Date Time Period Format 2/ R D8 DTP03 Date Time Period AN 1/ R Other Insurance Paid Date CCYYMMDD 2400 LX Service Line 2 R LX LX01 Assigned Number N0 1/6 554 R 2400 SV2 Institutional Service 3 R SV2 Line SV201 Product/Service AN 1/ R [Revenue Code] SV202-1 Product/Service S HC SV202-2 Product/Service AN 1/ S SV202-3 Procedure Modifier AN S SV202-4 Procedure Modifier AN S SV202-5 Procedure Modifier AN S SV202-6 Procedure Modifier AN S Last Updated: 6/16/2016 Page 34 of 42

39 Name/ Data SV203 Monetary Amount R 1/ R SV204 Unit or Basis for Measurement Code R SV205 Quantity R 1/ R SV207 Monetary Amount R 1/ S 2400 DTP Service Line Date 3 S DTP DTP01 Date/Time R 472 DTP02 Date Time Period 2/ R D8 or RD8 Format DTP03 Date Time Period 1/ R CCYYMMDD or CCYYMMDD- CCYYMMDD 2410 LIN Drug Identification 3 S LIN When billing a prescribed drug procedure code in 2400, this is required. LIN02 Product/Service R N4 LIN03 Product/Service AN 1/ R National Drug Code Last Updated: 6/16/2016 Page 35 of 42

40 Name/ Data 2410 CTP Drug Pricing 3 S CTP CTP04 Quantity N 1/ R Drug Unit Count CTP05-1 Unit or Basis for Measurement Code R Unit of Measurement Code ***Medicare Adjustment Amounts ** 2430 SVD Line Adjudication 3 S SVD Information SVD01 Identification Code AN 2/80 67 R MC01 SVD02 Monetary Amount R 1/ R Service Line Medicare Paid Amount SVD03 Composite Medical S Procedure Identifier SVD03-1 Product/Service R HC SVD03-2 Product/Service AN 1/ R Procedure Code SVD03-3 Procedure Modifier AN S Modifier SVD03-4 Procedure Modifier AN S Modifier Last Updated: 6/16/2016 Page 36 of 42

41 Name/ Data SVD03-5 Procedure Modifier AN S Modifier SVD03-6 Procedure Modifier AN S Modifier SVD03-7 Description AN 1/ S SVD04 Product/Service AN 1/ R Revenue Code SVD05 Quantity R 1/ R Quantity/Units 2430 CAS Line Adjustment 3 S CAS CAS01 Claim Adjustment 1/ R PR Group Code CAS02 Claim Adjustment Reason Code 1/ R 1 Medicare Deductible CAS03 Monetary Amount R 1/ R Medicare Deductible Amount CAS04 Quantity R 1/ S CAS05 Claim Adjustment 1/ S 2 - Coinsurance Reason Code CAS06 Monetary Amount R 1/ S Medicare Coinsurance Amount CAS07 Quantity R 1/ S Last Updated: 6/16/2016 Page 37 of 42

42 CAS08 Name/ Data Claim Adjustment Reason Code 1/ S 122 Medicare Psychiatric Reduction CAS09 Monetary Amount R 1/ S Medicare Psychiatric Reduction CAS10 Quantity R 1/ S 2430 CAS Line Adjustment 3 S CAS CAS01 Claim Adjustment 1/ R CO Group Code CAS02 Claim Adjustment Reason Code 1/ R Medicare Deductible Denial Reason (Action) Code CAS03 Monetary Amount R 1/ R DTP Line Adjudication Date DTP DTP01 Date/Time A/N 3/3 573 DTP02 Date Format AN 2/3 D8 DTP03 Payment Date N 35 Medicare Payment Date CCYYMMDD **The following are for reporting other insurance payment information 2430 SVD Line Adjudication 3 S SVD Last Updated: 6/16/2016 Page 38 of 42

43 Name/ Data Information SVD01 Identification Code AN 2/80 67 R OT01 SVD02 Monetary Amount R 1/ R Service Line Other Insurance Paid Amount SVD03-1 Product/Service R HC SVD03-2 Product/Service AN 1/ R Procedure Code SVD03-3 Procedure Modifier AN S Modifier SVD03-4 Procedure Modifier AN S Modifier SVD03-5 Procedure Modifier AN S Modifier SVD03-6 Procedure Modifier AN S Modifier SVD03-7 Description AN 1/ S SVD04 Product/Service AN 1/ R Revenue/Service Code SVD05 Quantity R 1/ R Quantity/Units 2430 CAS Line Adjustment 3 S CAS Last Updated: 6/16/2016 Page 39 of 42

44 Name/ Data CAS01 Claim Adjustment 1/ R PR Group Code CAS02 Claim Adjustment Reason Code 1/ R 1 Other Insurance Deductible CAS03 Monetary Amount R 1/ R Other Insurance Deductible Amount CAS04 Quantity R 1/ S CAS05 Claim Adjustment 1/ S 2 - Coinsurance Reason Code CAS06 Monetary Amount R 1/ S Other Insurance Coinsurance Amount CAS07 Quantity R 1/ S CAS08 Claim Adjustment Reason Code 1/ S 45 Other Insurance Allowed CAS09 Monetary Amount R 1/ S Other Insurance Allowed Amount CAS10 Quantity R 1/ S 2430 DTP Line Adjudication Date DTP DTP01 Date/Time A/N 3/3 573 DTP02 Date Format AN 2/3 D8 Last Updated: 6/16/2016 Page 40 of 42

45 Name/ Data DTP03 Payment Date N 35 Other Insurance Payment Date CCYYMMDD TRAILER SE Transaction Set Trailer 2 R SE SE01 Number of Included s N0 1/10 96 R SE02 Transaction Set Control Number AN 4/9 329 R GE Functional Group Trailer 2 R GE GE01 Number of Transaction Sets Included N0 1/6 97 R GE02 Group Control Number N0 1/9 28 R IEA Interchange Control 3 R IEA Number IEA01 Number of Included Functional Groups N0 1/5 I16 R IEA02 Interchange Control Number N0 9 I12 R Must be identical to the value in ISA13 Last Updated: 6/16/2016 Page 41 of 42

46 Appendix A. Please see Appendix_A_Vendor_Specs-5010.docx. Last Updated: 6/16/2016 Page 42 of 42