837I Institutional Health Care Claim - for Encounters

Companion Document 837I - Encounters 837I Institutional Health Care Claim - for Encounters Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care transaction for institutional encounters. The tables in this document provide information about 837 segments and data elements that require specific instructions to efficiently process. Use this companion document in conjunction with both the Transaction Set Implementation Guide Health Care Claim: Institutional, 837, ASC X12N 837 (004010X096), May 2000, and the subsequent Addenda (004010X096A1), October 2002, published by the Washington Publishing Co. EDI Transmission Structure Communications Transport Protocol Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Header (GS) Communications Session Interchange Control Wrap Functional Group 1 Wrap Functional Group 2 Wrap Transaction Set Transaction Set Transaction Set Transaction Set Transaction Set Header (ST) Detail Segment 1 Transaction Set Trailer (SE) Transaction Set Header (ST) Detail Segment 2 Transaction Set Trailer (SE) Functional Group Trailer (GE) Functional Group Header (GS) Transaction Set Header (ST) Detail Segment 1 Transaction Set Trailer (SE) Transaction Set Header (ST) Detail Segment 2 Transaction Set Trailer (SE) EDI Transaction Structure Envelope Envelope Envelope Interchange Control Header (ISA) Functional Group Header (GS) Transaction Set Header (ST) Header Detail Summary Transaction Set Trailer (SE) Functional Group Trailer (GE) Interchange Control Trailer (IEA) Functional Group Trailer (GE) Interchange Control Trailer (IEA) Communications Transport Protocol Page 1 of 20

1 X12 and HIPAA Compliance Checking, and Business Edits Level 1. X12 Compliance: Anthem Blue Cross returns a 997 Functional Acknowledgment to the submitter for every inbound 837 transaction received. Each transaction passes through edits to ensure that it is X12 compliant. If it successfully passes X12 syntax edits, a 997 Functional Acknowledgement is returned indicating acceptance of the transaction. If the transaction fails X12 syntax compliance, the 997 Functional Acknowledgement will also report the Level 1 errors in the AK segments and, depending on where the error occurred, will indicate that the entire interchange, functional group or transaction set has been rejected. Level 2. HIPAA IG Compliance - Sets: HIPAA Implementation Guide edits are strictly enforced. Anthem Blue Cross will return a Level 2 Status Report to the submitter indicating if a transaction set has been accepted or rejected. If the transaction set has been rejected, this report will indicate the Level 2 HIPAA compliance error(s) that occurred. 2 HIPAA Compliant s Follow the 837 Institutional IG precisely. Use HIPAA-Compliant codes from current versions of the sources listed in the 837 Institutional IG, Appendix C: External Sources. Acceptance of HIPAA standard codes or modifiers will not alter Anthem Blue Cross covered benefits or current payment policies, guidelines or processes. 3 Uppercase Letters All alpha characters must be submitted in UPPERCASE letters only. 4 Delimiters Enterprise EDI Gateway/Clearinghouse accepts any of the standard delimiters as defined by the ANSI standards. The more commonly used delimiters include the following: Data Element Separator, Asterisk, (*) Sub-Element Separator, Vertical Bar, ( ) Segment Terminator, Tilde, (~) These delimiters are for illustration purposes only and are not specific recommendations or Page 2 of 20

requirements. 5 Coordination of Benefits Specific 837 data elements work together to coordinate benefits between Anthem Blue Cross and Medicare or other carriers. The tables in the section that follow (Loop 2320, 2330A, and 2330B), identify the data elements that pertain to coordination of benefits with Medicare (Provider-to-Payer-to- Payer COB model) and with other carriers (Payer-to-Provider-to-Payer COB model). Anthem Blue Cross recognizes submission of an 837 to a sequential payer populated with data from the previous payer s 835 (Health Care Claim Payment/Advice). Based on the information provided and the type of policy, the claim will be adjudicated without the paper copy of the Explanation of Benefits from Medicare or the primary carrier. When more than one payer is involved on a claim, payer sequencing is as follows: If a secondary payer is indicated, then all the data elements from the primary payer must also be present. If a tertiary payer is involved, then all the data elements from the primary and secondary payer must also be present. If these data elements are omitted, Anthem Blue Cross will fail the particular claim. 6 Taxonomy s (PRV) The Healthcare Provider Taxonomy code set divides health care providers into hierarchical groupings by type, classification, and specialization, and assigns a code to each grouping. The Taxonomy consists of two parts: individuals (e.g., physicians) and non-individuals (e.g., ambulatory health care facilities). All codes are alphanumeric and are 10 positions in length. These codes are not assigned to health care providers; rather, health care providers select the taxonomy code(s) that most closely represents their education, license, or certification. If a health care provider has more than one taxonomy code associated with it, a health plan may prefer that the health care provider use one over another when submitting claims for certain services. It is strongly recommended that the taxonomy be populated in Loops 2000A and 2310A PRV segment for all applicable claims that you are filing. Refer to the CMS website for a listing of codes, www.wpc-edi.com/taxonomy. Taxonomy (PRV) 837I Institutional Claims The taxonomy should be populated in Loops 2000A and 2310A PRV segment for all applicable claims that you are filing. PRV Loop 2000A Billing/Pay-to Provider PRV01 = Provider BI Billing Provider Specialty Information PT Pay to Provider Specialty Information PRV02 = ZZ Health Care Provider Taxonomy code PRV03 = (Provider Taxonomy ) Strongly recommended to include a taxonomy on all applicable claims that you are filing (NOTE to Clearinghouses DO NOT USE Defaults) Example: PRV*BI*ZZ*203BA0200N~ PRV Loop 2310A Attending Provider PRV01 = Provider AT Attending Provider Specialty Information PRV02 = ZZ Health Care Provider Taxonomy code PRV03 = (Provider Taxonomy ) Strongly recommended to include a taxonomy on all applicable claims that you are filing (NOTE to Clearinghouses DO NOT USE Defaults) Example: PRV*AT*ZZ*363LP0200N~ Page 3 of 20

7 Numeric s, s and Unit Amounts Anthem Blue Cross accepts monetary amounts only in US dollars. If codes related to foreign currencies are used, then the encounter will be denied. Anthem Blue Cross recognizes unit amounts in whole numbers only. The encounter will also be denied for negative values submitted in any of the three data elements in Loop 2400, SV2 Institutional Service Line (See 837 Institutional IG, P.439): SV203 Line Item Charge Amount SV205 Quantity Service Unit Count SV207 Line Item Denied Charge or Non-Covered Charge Amount Page 4 of 20

Enveloping EDI envelopes control and track communications between you and Anthem. One envelope may contain many transaction sets grouped into functional groups. The envelope consists of the folowing: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) 837 EDI Transaction Structure Interchange Control Header (ISA) Functional Group Header (GS) Transaction Set Header (ST) Envelope Envelope Envelope Header Detail Transaction Set Trailer (SE) Functional Group Trailer (GE) Interchange Control Trailer (IEA) Page 5 of 20

837 Envelope Control Segments Inbound 1 837 Health Care Claim Interchange Control Header (ISA) The ISA segment is the beginning, outermost envelope of the interchange control structure. Containing authorization and security information, it also clearly identifies the sender, receiver, date, time, and interchange control number. Anthem requests that all data entered in the ISA-IEA segment be in UPPERCASE. Segment 837 Institutional Health Care Claim Interchange Control Header (ISA) Specific to Anthem ISA ISA01 00 00 - No Authorization Information Present Interchange Auth Info Qualifier Control ISA02 (10 Spaces) Enter 10 positions. Header Authorization Info ISA03 Security Info Qualifier 00 00 - No Security Information Present ISA04 Security Information ISA05 Interchange ID Qualifier ISA06 Interchange Sender ID ISA07 Interchange ID Qualifier ISA08 Interchange Rec ID ISA09 Interchange Date ISA10 Interchange Time ISA11 Interchange Control Standards Identifier ISA12 Interchange Control Version Number ISA13 Interchange Cntrl No. (10 Spaces) Enter 10 positions. ZZ (Submitter ID) ZZ ENCBCCA (YYMMDD) (HHMM) U ISA14 Ack Requested ISA15 Usage Indicator ISA16 (X) Component Element Separator ZZ - Mutually Defined Format - Fixed length of 15 positions, alphanumeric. Left-justified followed by spaces. Identical to GS02. ZZ - Mutually Defined ENBCCA - Anthem Blue Cross (for Encounters) Left-justified followed by spaces. must be a valid date in YYMMDD format. must be a valid time in HHMM format. U - U.S. EDI Community of ASC X12, TDCC, and UCS 00401 00401 - Draft Standards for Trial Used Approved for Publication by ASC X12 Procedures Review Board through October 1997 (Assigned by Sender) Format - Fixed length 9 positions, numeric. Unique value greater than zero and not used in any HIPAA transmission within last 365 calendar days. Right-justified, filled with leading zeroes. Identical to IEA02. 0, 1 0 - No Acknowledgment Requested 1 - Interchange Acknowledgment Requested P, T Submitter ID must be approved to submit production data (P - Production Data; T - Test Data). X - 1 character contained in Basic or Extended Character set. must not equal A-Z, a-z, 0-9, "space", and special characters which may appear in text data (i.e., hyphen, comma, period, apostrophe). Page 6 of 20

2 837 Health Care Claim Functional Group Header (GS) The GS segment identifies the collection of transaction sets that are included within the functional group. More specifically, the GS segment identifies the functional control group, sender, receiver, date, time, group control number and version/release/industry code for the transaction sets. Use the following table, specific to Anthem, to supplement the 837 Implementation Guides. This information does not modify the 837 Implementation Guides. Segment 837 Institutional Health Care Claim Functional Group Header (GS) Specific to Anthem GS Functional Group Header GS01 Functional Identifier GS02 Application Sender's GS03 Application Receiver's GS04 Date GS05 Time GS06 Group Control Number GS07 Responsible Agency GS08 Version / Release / Industry Identifier HC (Submitter ID) ENCBCCA (CCYYMMDD) (HHMM) (Assigned by Sender) X 004010X096A1 HC - Health Care Claim (837) Encounter Format - 2-15 positions, alphanumeric. Left-justified with no trailing zeroes or spaces. Identical to ISA06. Routing of batched transactions to: ENCBCCA - Anthem Blue Cross (for Encounters) must be a valid date in CCYYMMDD format. must be a valid time in HHMM format. Format - 1-9 positions, numeric. Unique value greater than zero and not used in any HIPAA transmission within last 365 calendar days. Left-justified with no trailing zeroes or spaces. Identical to GE02. X - Accredited Standards Committee X12 Operationally used to identify the transaction: 004010X096A1-837 Institutional Claim NOTE. Critical Batching and Editing Information. **Transactions must be batched in separate functional group by Application Receiver s (GS03). ***Group Control Number (GS06) may not be duplicated by submitter. Files containing duplicate or previously received group control numbers will be rejected. Page 7 of 20

3 837 Health Care Claim Functional Group Trailer (GE) The GE segment indicates the end of the functional group and provides control information. Use the following table, specific to Anthem, to supplement the 837 Implementation Guides. This information does not modify the 837 Implementation Guide. Segment 837 Institutional Health Care Claim Functional Group Trailer (GE) Specific to Anthem GE Functional Group Trailer GE01 Number of Transaction Sets Included GE02 Group Control Number (Total Number of Transaction Sets in Functional Group or Transmission) (Control Number) Format - 1-6 positions, numeric. Left-justified with no trailing zeroes or spaces. Format - 1-9 positions, numeric. Left-justified with no trailing zeroes or spaces. Identical to GS06. 4 837 Health Care Claim Interchange Control Trailer (IEA) The IEA segment is the ending, outmost level of the interchange control structure. It indicates and verifies the number of functional groups included with the interchange and the interchange control number (the same number indicated in the ISA segment). Use the following table, specific to Anthem, to supplement the 837 Implementation Guides. This information does not modify the 837 Implementation Guide. Segment 837 Institutional Health Care Claim Interchange Control Trailer (IEA) Specific to Anthem IEA Interchange Control Trailer IEA01 Number of Included Functional Groups IEA02 Interchange Control Number (Number of Functional Groups GS/GE Pairs in Interchange) (Control Number) Format - 1-5 positions, numeric. Left-justified with no trailing zeroes or spaces. Format - Fixed length 9 positions, numeric. Unique value greater than zero. Identical to ISA13. Page 8 of 20

837 Institutional Claim Header The 837 Claim Header identifies the start of a transaction, the specific transaction set, and its business purpose. Also, when a transaction set uses a hierarchical data structure, a data element in the header, BHT01 (Hierarchical Structure ) relates the type of business data expected within each level. The following table indicates the specific values of the required header segments and data elements for Anthem Blue Cross processing. IG Segment Beginning of Hierarchical Transaction P.57 BHT Beginning of Hierarchical Transaction P.60 REF Transmission Type BHT06 Transaction Type Loop ID 1000A Submitter Name P.61 NM1 Submitter Name P.65 PER Administrative Communications Contact RP REF02 004010X096A1 Transmission Type NM109 PER03 Communication Qualifier Loop ID 1000B Receiver Name P.67 NM1 Receiver Name NM103 Last Name or Organization Name 837 Institutional Health Care Claim Header NM109 (Submitter UPPERCASE TE ANTHEM BLUE CROSS Specific to Anthem Blue Cross RP - Reporting; required to indicate the batch contains all encounters. *Refer to separate 837I Companion Document for submission of Institutional Claims. Will not be used to distinguish between test and production. EDI assigned Sender ID. Equals the value entered in ISA06 and GS02. TE - Telephone For support purposes, Anthem Blue Cross requests the telephone number of the submitter be identified. ANTHEM BLUE CROSS - identifies receiver 47198 47198 - Anthem Blue Cross Page 9 of 20

837 Institutional Claim Detail The 837 Claim Detail level has a hierarchical level (HL) structure based on the participants involved in the transaction. The three levels for the participant types include: 1) Information Source (Billing/Pay-to Provider) 2) Subscriber (Can be the Patient when the Patient is the Subscriber) 3) Dependent (Patient when the Patient is not the Subscriber) Page 10 of 20

1 837 Health Care Claim Detail: Billing/Pay-to Provider Hierarchical Level The first hierarchical level (HL) of the 837 detail is the Information Source HL, also known as the Health Care Claim Detail, Billing/Pay-to Provider. IG Segment Loop ID 2000A Billing/Pay-to Provider Hierarchical Level P.71 PRV PRV01 BI Billing/Pay-to Provider Specialty Information P.73 CUR Foreign Currency Information 837 Institutional Health Care Claim Detail Billing/Pay-to Provider Hierarchical Level Provider PRV03 CUR02 Currency (Provider Taxonomy ) USD BI - Billing Specific to Anthem Blue Cross When using NPI, enter the taxonomy code that applies to the service on the claim that you are filing (NOTE to Clearinghouses - DO NOT DEFAULT). USD - US dollars Monetary amounts recognized in US dollars only. Loop ID 2010AA Billing Provider Name P.76 NM1 Billing Provider NM108 ID Qualifier XX 24 XX - National Provider Identifier 24 - Employer's Number Name NM109 (Billing Provider NPI ('XX') for Non-Exempt providers Primary ID No.) Tax ID ('24') for Exempt providers P.82 REF Segment required to accurately identify the Billing Provider. Billing Provider Secondary REF01 ID Qualifier 1C 1D EI SY 1C - Medicare Provider Number 1D - Medicaid Number EI - Employer's Number SY - Social Security Number REF02 (Billing Provider Additional Assigned Prov No. ('1C', '1D') - for Exempt Providers Provider's Tax ID ('EI') Provider's Social Security Number ('SY') Loop ID 2010AB Pay-to Provider Name P.91 NM1 NM108 XX XX - National Provider Identifier Pay-to Provider ID Qualifier 24 24 - Employer's Number Name NM109 (Pay-to Prov Primary ID No.) Tax ID ('24') for Exempt providers NPI ('XX') for Non-Exempt providers P.97 REF Segment required to accurately identify the Pay-to Provider. Pay-to Provider REF01 1C 1C - Medicare Provider Number Secondary ID Qualifier 1D EI SY 1D - Medicaid Number EI - Employer's Number SY - Social Security Number REF02 (Pay-to Provider Additional Assigned Prov No. ('1C', '1D') - for Exempt Providers Provider's Tax ID ('EI') Provider's Social Security Number ('SY') Page 11 of 20

2 837 Health Care Claim Detail: Subscriber Hierarchical Level The second hierarchical level (HL) of the 837 Health Care Claim Detail is the Subscriber HL. 837 Institutional Health Care Claim Detail Subscriber Hierarchical Level IG Segment Loop ID 2000B Subscriber Hierarchical Level P.101 SBR Subscriber SBR01 Payer P, S, T Information Responsibility Sequence Number SBR03 See 837I IG Group Number Loop ID 2010BA Subscriber Name P.108 NM1 NM102 1 Subscriber Name Entity Type Qualifier NM109 (Subscriber Primary Loop ID 2010BC Payer Name P.126 NM1 Payer NM103 Payer Name ANTHEM BLUE CROSS Name NM108 ID Qualifier PI NM109 (Payer Primary Group number on the card or from eligibility check should be submitted. If group number is not provided, '99999' may be submitted. 1 - Individual Specific to Anthem Blue Cross (ABC) Usage of 'S' or 'T' accompanies information populated in Loop 2320 and 2330 for COB adjudication information. Absence of this data will delay processing of the claim. Subscriber ID - 9-12 bytes. It is strongly recommended to have software support 20 bytes. ***ALL ALPHA CHARACTERS MUST BE IN UPPERCASE LETTERS. Enter the ID Number exactly as it appears on the front of the ID card, including ANY PREFIX. ANTHEM BLUE CROSS - identifies payer PI - Payer 47198 - Anthem Blue Cross Page 12 of 20

3 837 Health Care Claim Detail: Patient Hierarchical Level The third hierarchical level (HL) of the 837 Health Care Claim Detail is the Patient HL. IG Segment Loop ID 2300 Claim Information P.157 CLM CLM01 Claim Claim Information Submitter's CLM02 Monetary P.167 DTP Statement Dates P.187 REF Claim ID No. for Clearing Houses and Other Transmission Intermediaries P.191 REF Original Number (ICN/DCN) 837 Institutional Health Care Claim Detail Patient Hierarchical Level Amount CLM05-3 Claim Frequency Type DTP03 Date Time Period REF01 ID Qualifier REF02 REF01 ID Qualifier REF02 (Patient Control Number) (Total Claim Charge Amount) (Third Position of Uniform Billing Claim Form Bill Type) (Statement From or To Date) D9 ( Added Network Trace Number) F8 (Claim Original Number) Specific to Anthem Blue Cross (ABC) Maximum of 20 alphanumeric characters. is returned on outbound 835 and other transactions. must equal the total amount of submitted charges for service lines in Loop 2400 SV203. If '7' (replacement) or '8' (void/cancel) then the Original Number (ICN/DCN) data segment (Loop 2300 REF02) is required and must contain ABC originally assigned claim number. Valid medical codes will be based on the "Statement From Date". D9 - Claim Number Will be returned on Level 2 Status Report, if submitted. F8 - Original Number Represents the claim number assigned by ABC. Providers should submit the original claim number indicated on the 835 when Loop 2300 CLM05-3 Claim Freq. Type equals '7' or '8'. Page 13 of 20

837 Institutional Health Care Claim Detail Patient Hierarchical Level IG Segment Loop ID 2300 Claim Information (CONT'D) P.203 NTE NTE01 ADD Line Note Note NTE02 Description (Line Note Text) Specific to Anthem Blue Cross (ABC) ADD - Additional Information When it is necessary to bill for unlisted HCPCS (NOC codes) in Loop 2400 SV101-2 (Procedure ), include the drug and dosage. When a copay is collected from a member please include as described below. Amounts will be transmitted in the first 11 bytes of the NTE field: Positions 1-5 =COPAY Positions 6-11 to reflect the actual amount. Any NTE data that needs to be submitted must start at position 12 of the element. example for $10 Copay without additional text NTE*ADD*COPAY000010 P.204 K3 File Information P.227 HI Health Care Information K301 Fixed Format Information HI01-2 -- HI03-2 Diagnosis Y N U W 1 X or Z Format: POA<value/s> See Source 131: ICD-9-CM example for $10 Copay with additional text NTE*ADD*COPAY000010ADDITIONAL TEXT Effective 1/1/08, Acute Care Hospitals must submit a POA indicator for every principal and other diagnosis on inpatient (TOB 11x and 12x) acute care claims. Y-Yes; N-No; U-unknown; W-Clinically Undetermined; 1-Unreported/Not Used/Exempt; X or Z-POA data Include diagnosis information to promote more efficient adjudication and processing of bill type 4XX, 5XX, and 14 transactions. ICD-9-CM Guide requires diagnosis codes to the highest level of specificity. A code is invalid if it has not been coded to Page 14 of 20

IG Segment Specific to Anthem Blue Cross Loop ID 2310C Other Provider Name P.335 NM1 NM108 24 24 - Employer's Number Other Provider ID Qualifier XX XX - HCFA National Provider Identifier Name NM109 ID (Other Provider Primary Tax ID ('24') for Exempt providers NPI ('XX') for Non-Exempt providers P.340 REF Other Provider Secondary Segment required to accurately identify the Other Provider. REF01 1C ID 1D Qualifier EI REF02 SY (Other Provider Secondary Loop ID 2310E Service Facility Name P.349 NM1 NM108 24 Service ID Qualifier XX Facility Name NM109 (Laboratory / ID Facility Primary P.357 REF Service Facility REF01 Secondary ID Qualifier 837 Institutional Health Care Claim Detail Patient Hierarchical Level 1C - Medicare Provider Number 1D - Medicaid Number EI - Employer's Number SY - Social Security Number Assigned Prov No. ('1C', '1D') - for Exempt Providers Provider's Tax ID ('EI') Provider's Social Security Number ('SY') 24 - Employer's Number XX - HCFA National Provider Identifier Tax ID ('24') for Exempt providers NPI ('XX') for Non-Exempt providers Segment required to accurately identify the Service Facility Location. 1C 1C - Medicare Provider Number 1D 1D - Medicaid Number EI EI - Employer's Number SY SY - Social Security Number REF02 (Laboratory or Facility Secondary Assigned Prov No. ('1C', '1D') - for Exempt Providers Provider's Tax ID ('EI') Provider's Social Security Number ('SY') Page 15 of 20

IG Segment Loop ID 2310A Attending Physician Name P.321 NM1 NM108 XX Attending ID Qualifier 24 Physician Name P.324 PRV Attending Physician Specialty Information P.326 REF Attending Physician Secondary NM109 PRV03 (Attending Physician Primary (Provider Taxonomy ) Specific to Anthem Blue Cross XX - National Provider Identifier 24 - Employer's Number NPI ('XX') for Non-Exempt providers Tax ID ('24') for Exempt providers When using NPI, enter the taxonomy code that applies to the service on the claim that you are filing (NOTE to Clearinghouses - DO NOT DEFAULT). Segment required to accurately identify the Attending Physician. REF01 ID Qualifier 1C 1D EI 1C - Medicare Provider Number 1D - Medicaid Number EI - Employer's Number SY REF02 (Attending Physician Secondary Loop ID 2310B Operating Physician Name P.328 NM1 NM108 24 Operating ID Qualifier XX Physician NM109 Name ID P.333 REF Operating REF01 Physician ID Secondary Qualifier REF02 837 Institutional Health Care Claim Detail Patient Hierarchical Level (Operating Physician Primary SY - Social Security Number Assigned Prov No. ('1C', '1D') - for Exempt Providers Provider's Tax ID ('EI') Provider's Social Security Number ('SY') 24 - Employer's Number XX - HCFA National Provider Identifier Tax ID ('24') for Exempt providers NPI ('XX') for Non-Exempt providers Segment required to accurately identify the Operating Physician. 1C 1C - Medicare Provider Number 1D 1D - Medicaid Number EI EI - Employer's Number SY SY - Social Security Number (Operating Physician Secondary ID) Assigned Prov No. ('1C', '1D') - for Exempt Providers Provider's Tax ID ('EI') Provider's Social Security Number ('SY') Page 16 of 20

IG Segment Specific to Anthem Blue Cross (ABC) When ABC is secondary or tertiary, enter data elements as noted for Loops 2320, 2330A, & 2330B. COB claims without other payer adjudication information will delay processing. Loop ID 2320 Other Subscriber Information P.359 SBR Other Subscriber Information SBR01 Payer Responsibility Sequence Number P S T P - Primary; S - Secondary; T - Tertiary Represents the other payer(s) level of responsibility for payment of this claim P.365 CAS Claim Level Adjustment P.371 AMT Payer Prior Payment P.372 AMT COB Total Allowed Amount P.373 AMT COB Total Submitted Charges P.374 AMT Diagnostic Related Group (DRG) Outlier 837 Institutional Health Care Claim Detail Patient Hierarchical Level Use the CAS segments to report prior payer(s) claim level adjustments that cause the amount paid to differ from the originally submitted charge amount. Institutional adjustments recognized at claim level only. CAS01 Claim Adjustment Group CO - Contractual Obligation CR - Correction & Reversals OA - Other Adjustments CAS02,5,8,11,14,17 Claim Adjustment 1 Reason 2 CAS03,6,9,12,15,18 (Adjustment Amount) CAS01 CO - Contractual Obligation Claim Adjustment CR - Correction & Reversals Group OA - Other Adjustments CAS02,5,8,11,14,17 Claim Adjustment (Adjustment Reason Reason ) CAS03,6,9,12,15,18 (Adjustment Amount) Amount Qualifier AMT02 Amount Qualifier AMT02 Amount Qualifier AMT02 Amount Qualifier AMT02 C4 (Payer Prior Payment) B6 (Allowed Amount) T3 (Tot Clm Level Submitted Charge) ZZ (Claim DRG Outlier Amount) PI - Payer Initiated Reductions PR - Patient Responsibility 1 - Deductible Amount 2 - Coinsurance Amount Represents the deductible as reported by the other payer PI - Payer Initiated Reductions PR - Patient Responsibility NON-COVERED CHARGES Represents the adjustment reason code for non-covered as reported by other payer. Represents the non-covered amount as reported by other payer. C4 - Prior Payment - Actual Represents the Prior Payer Payment. B6 - Allowed - Actual Represents the Allowed Amount. T3 - Total Submitted Charges Represents the Coordination of Benefits Total Submitted Charge Amount. ZZ - Mutually Defined DEDUCTIBLE & COINSURANCE Represents the Claim DRG Outlier Amount. Page 17 of 20

IG Segment Specific to Anthem Blue Cross (ABC) When ABC is secondary or tertiary, enter data elements as noted for Loops 2320, 2330A, & 2330B. COB claims without other payer adjudication information will delay processing. Loop ID 2320 Other Subscriber Information (cont'd) P.376 AMT N1 N1 - Net Worth COB Total Amount Qualifier Medicare Paid Amount AMT02 (Total Medicare Paid Amount) Represents the Total Medicare Paid Amount. P.378 AMT Medicare Paid Amount Qualifier KF KF - Net Paid Amount Amount - 100% AMT02 (Medicare Paid at Represents the COB Medicare Paid 100%) Amount at 100%. P.380 AMT PG PG - Payoff Medicare Paid Amount Qualifier Amount - 80% AMT02 (Claim Level Allowed Charge Represents the amount that Medicare Paid at 80%. Paid at 80%) P.382 AMT AA AA - Allocated COB Medicare Amount Qualifier A Trust Fund Paid Amount AMT02 (Amount Paid by Medicare Part A) Represents the Paid From Part A Medicare Trust Fund Amount. P.384 AMT B1 B1 - Benefit Amount COB Medicare Amount Qualifier B Trust Fund Paid Amount AMT02 (Amount Paid by Medicare Part B) Represents the Paid From Part B Medicare Trust Fund Amount. P.386 AMT A8 A8 - Non-covered Charges - Actual COB Total Non- Amount Qualifier Covered Amount AMT02 (Non-covered Clm Lvl Charge) Represents the amount for the total of noncovered claim level charges. P.387 AMT COB Total Amount Qualifier YT YT - Denied Denied Amount AMT02 (Tot Clm Lvl Denied Charges) Represents the amount the other payer identified as exceeding existing benefits. P.388 DMG Other Subscriber Information 837 Institutional Health Care Claim Detail Patient Hierarchical Level DMG01 Date Time Period Format Qualifier DMG02 Date Time Period DMG03 Oth Insured Gender Cd P.390 OI OI03 Other Insurance Yes/No Condition or Coverage Response Indicator Information OI06 Release of Information D8 (Other Insured Birth Date) F M U N Y (Release of Information ) D8 - Date expressed in format CCYYMMDD Represents other insured's date of birth. F - Female; M - Male; U - Unknown N - No; Y - Yes (same values as Loop 2300 CLM08) Indicates provider has an authorization of release on file (same value as Loop 2300 CLM09). Page 18 of 20

IG Segment Loop ID 2400 Service Line P.445 SV2 SV201 Institutional Product/Service ID Service Line SV202-1 Product/Service ID Qualifier SV204 Units or Basis for Measurement SV205 Quantity Loop ID 2410 Drug P.480 LIN LIN03 Drug Product/Service ID (Service Line Revenue ) HC DA UN (Service Unit Count) (National Drug ) Loop ID 2430 Service Line Adjudication Information P.488 SVD SVD04 (Service Line Service Line Product/Service ID Revenue ) Adjudication P.492 CAS Service Line Adjustment P.500 DTP Service Adjudication Date 837 Institutional Health Care Claim Detail Patient Hierarchical Level CAS02,5,8,11,14,17 Claim Adjustment Reason CAS03,6,9,12,15,18 CAS04,7,10,13,16,19 Quantity DTP03 Date Time Period (Adjustment Reason ) (Adjustment Amount) (Adjustment Quantity) (Service Adjudication or Payment Date) Specific to Anthem Blue Cross Required on outpatient claims when an appropriate code exists. HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) s DA - Days UN - Units cannot exceed 9 digits. NDC number reported for prescribed drugs and biologics when required by government regulation. Revenue code billed by provider. Identifies the reason for claim being adjusted. Represents the amount being adjusted. Represents the units of service being adjusted. Represents when the primary payer made payment and is recognized for processing Coordination of Benefits. Page 20 of 20