Companion Guide for the 005010X223A1 Health Care Claim: Institutional (837I) Lines of Business: Private Business, 65C Plus, QUEST, Blue Card, FEP, Away From Home Care Delimiter: Data Element (*) Asterisk Separator Delimiter: Composite Element (:) Colon Separator Delimiter: Segment Terminator (<NL>) New Line Hex Value 0A (line feed) or (~) Tilde ISA Interchange Control Header ISA05 Interchange ID ZZ = Mutually Defined ISA06 Interchange Sender ID HMSA assigned submitter ID ISA07 Interchange ID 30 US Federal Tax ID ISA08 Interchange Receiver ID 990040115 Both ISA07 must be equal to 30 and ISA08 must be equal to 990040115, otherwise HMSA will reject the file. ISA11 Repetition Separator ( { ) Left Brace ISA12 Interchange Control Version 00501 ISA13 Interchange Control Use a unique number assigned by the sender to identify the interchange data. It is used as an audit trail and in a check for duplicate exchange. A Control should never be reused. ISA14 Acknowledgement Requested 0, 1 0 = TA1 will not be created ISA15 Usage Indicator P, T P for production. T for test. HMSA will reject the file received with T in production and vice-versa. ISA16 Component Element : (Composite delimiter) Separator GS Functional Group Header HMSA will allow multiple Submitters within a GS GE functional group. HMSA will allow more than one Line of Business in an ISA IEA interchange GS02 Application Sender Code ACC = Accounting GS03 Application Receiver Code AH = Away From Home Care BC = Blue Card FE = Federal Employee Program (FEP) QT = QUEST RC = 65C Plus RG = Private Business CLM = more than one line of business included in the Functional Group. The subscriber number will determine which line of business the claim will be processed under. GS06 Group Control Group Control should be unique 1
for every GS GE functional group transmitted within the same day. A unique value will facilitate reconciliation with 999 functional acknowledgement transaction. GS08 Version/Release/Industry Identifier Code 005010X223A1 for transactions submitted in version 5010A1. ST Transaction Set Header Recommend only one Billing Provider in each ST SE Transaction set. Providers can submit more than one Billing Provider in each ST SE but HMSA rejects will be done at the ST SE transaction set level. ST03 Implementation Convention 005010X223A1 Reference BHT Beginning Of Hierarchical BHT03 Transaction Originator Application Transaction ID Use a unique number in this field. The assigned number must be unique within each file creation date (BHT04). This will be used as a duplicate check for each transaction. The fields for the duplicate check are: BHT03 (submission number), 1000A. NM109 (Submitter ID), BHT04 (create date), GS03 (line of business). BHT06 Claim or Encounter ID List CH = Chargeable 1000A - Submitter Name NM1 1000A Submitter Name NM109 Submitter Identifier HMSA Assigned Submitter ID 1000B Receiver Name NM1 1000B Receiver Name NM103 Receiver Name Use HAWAII MEDICAL SERVICE ASSOCIATION NM109 Receiver Primary Identifier Use 990040115 (HMSA s Federal Tax ID) 2000A Billing Provider Hierarchical Level - This Loop is required when Loop 2310E is not used. HL 2000A Billing Provider Hierarchical Level PRV 2000A Billing Provider Specialty CUR 2000A Foreign Currency 2010AA Billing Provider Name NM1 2010AA Billing Provider Name N3 2010AA Billing Provider Address Use the physical address not the mailing address. HMSA is using this information for processing. N301 Address Billing Provider street address N4 2010AA Billing Provider City/State/Zip Code N403 Postal Code Required for processing. Format should 2
be Zip Code + 4 digits with no hyphen or spaces. REF 2010AA Billing Provider Tax PER 2010AA Billing Provider Contact 2010AB Pay To Address Name NM1 2010AB Pay To Address Name N3 2010AB Pay-To Address N301 Address information N4 2010AB Pay-To Provider City/State/Zip Code N403 Postal Code When submitted, format should be Zip Code + 4 digits with no hyphen or spaces. 2010AC Pay-To Plan Name NM1 2010AC Pay-To Plan Name N3 2010AC Pay-To Plan Address N4 2010AC Pay-To Plan City, State, Zip Code REF 2010AC Pay-To Plan Secondary REF 2010AC Pay-To Plan Tax 2000B Subscriber Hierarchical Level HL 2000B Subscriber Hierarchical Level SBR 2000B Subscriber SBR09 Claims Filing Indicator Code List BL = Blue Cross/Blue Shield FI = Federal Employees Program 2010BA- Subscriber Name NM1 2010BA Subscriber Name NM102 Entity Type 1, 2 1 = Person = Subscriber NM103 Subscriber Last Name Do not use the following special pound sign (#) or caret symbol (^) NM104 Subscriber First Name Do not use the following special pound sign (#) or caret symbol (^) NM108 Code MI or II MI = HMSA ID NM109 Subscriber Primary Identifier HMSA Subscriber See HMSA Subscriber ID details in the Trading Partner Manual. N4 2010BA Subscriber City/State/Zip Code DMG 2010BA Subscriber Demographic DMG03 Subscriber Gender Code M, F, U M = Male or F = Female Use only if Subscriber is Patient (SBR02 3
= 18) REF 2010BA Subscriber Secondary REF 2010BA Property And Casualty Claim 2010BB Payer Name NM1 2010BB Payer Name NM103 Payer Name HAWAII MEDICAL SERVICE ASSOCIATION NM109 Payer Identifier 990040115 = HMSA s Federal Tax ID. REF 2010BB Payer Secondary REF 2010BB Billing Provider Secondary 2000C Patient Hierarchical Level HL 2000C Patient Hierarchical Level PAT 2000C Patient 2010CA Patient Name NM1 2010CA Patient Name N3 2010CA Patient Address N4 2010CA Patient City/State/Zip Code DMG 2010CA Patient Demographic DMG03 Patient Sex M, F, U M = Male or F = Female REF 2010CA Property and Casualty Claim 2300 Claim CLM 2300 Claim CLM01 Claim Submitter Identifier/Patient Account 4 Patient Account Do not use the following special characters: Asterisk (*), equal sign (=), pound sign (#) or caret symbol (^) Use only 1 = Orig or 7 = Resub CLM05-3 Claims Frequency Type Code - Submission Reason Code DTP 2300 Discharge Hour DTP 2300 Statement Dates DTP 2300 Admission Date/Hour DTP02 Date/Time Period Format DTP 2300 Date- Repricer Received Date CL1 2300 Institutional Claim Code PWK 2300 Claim Supplemental CN1 2300 Contract AMT 2300 Patient Estimated Amount Due REF 2300 Service Authorization Exception Code REF 2300 Referral REF01 Reference 9F 9F Referral D8, DT DT = Date and Time Expressed in Format CCYYMMDDHHMM
REF02 Referral Do not use the following special pound sign (#) or caret symbol (^). Do not submit more than 15 characters REF 2300 Prior Authorization REF01 Reference G1 G1 Prior Authorization REF02 Prior Authorization Do not use the following special pound sign (#) or caret symbol (^). Do not submit more than 15 characters REF 2300 Payer Claim Control REF 2300 Repriced Claim REF 2300 Adjusted Repriced Claim REF 2300 Investigational Device Exemption REF 2300 Claim Identifier for Transmission Intermediaries REF 2300 Auto Accident State REF 2300 Medical Record REF 2300 Demonstration Project Identifier REF 2300 Peer Review Organization (PRO) Approval K3 2300 File NTE 2300 Claim Note NTE 2300 Billing Note CRC 2300 EPSDT Referral HI 2300 Principal Diagnosis HI01-9 Yes/No Condition or Response Code HI 2300 Admitting Diagnosis HI 2300 Patient s Reason for Visit HI 2300 External Cause of Injury HI 2300 Diagnosis Related Group (DRG) HI 2300 Other Diagnosis HI 2300 Principal Procedure HI 2300 Other Procedure HI Occurrence Span HI 2300 Occurrence HI 2300 Value HI 2300 Condition HI 2300 Treatment Code HCP 2300 Claim Pricing/Repricing List Use the POA information at this level instead of K3 segment. 5
2310A Attending Provider Name NM1 2310A Attending Provider Name PRV 2310A Attending Provider Specialty 2310B Operating Physician Name NM1 2310B Operating Physician Name REF 2310B Operating Physician 2310C - Other Operating Physician Name NM1 2310C Other Operating Physician Name REF 2310C Other Operating Physician 2310D - Rendering Provider Name NM1 2310D Rendering Provider Name REF 2310D Rendering Provider 2310E - Service Facility Location Name NM1 2310E Service Facility Location N3 2310E Service Facility Location Address N4 2310E Service Facility Location City/State/Zip Code N403 Postal Code Required for processing. Format should be ZIP Code + 4 positions with no hyphen or spaces. REF 2310E Service Facility Location 2310F Referring Provider Name NM1 2310F Referring Provider Name REF 2310F Referring Provider 2320 Other Subscriber Other Sub/ Other Payer loops repeated once for each Payer SBR 2320 Other Subscriber SBR01 Payer Responsibility Sequence Code List Identifies Primary, Secondary or Tertiary for Payer in 2330B Other Payer Names Loop. P = Primary S = Secondary T = Tertiary SBR09 Claim Filing Indicator Code List Use BL (Blue Cross/Blue Shield) when HMSA is Other Payer. A valid Claim Filing Indicator Code is required prior to the mandated use of Plan ID. Not used after Plan ID is mandated. CAS 2320 Claim Level Adjustments AMT 2320 Coordination of Benefits (COB) Payer Paid Amount 6
AMT 2320 Remaining Patient Liability AMT 2320 Coordination of Benefits (COB) Total Non-Covered Amount OI 2320 Other Insurance Coverage MIA 2320 Inpatient Adjudication MOA Outpatient Adjudication 2330A Other Subscriber Name NM1 2330A Other Subscriber Name NM108 Code MI, II When HMSA is Other Payer, use MI NM109 Code/Other Insured Identifier/Subscriber Primary Identifier 2330B Other Payer Name NM1 2330B Other Payer Name NM103 Last Name or Organization Name HMSA Subscriber See HMSA Subscriber ID details in the Trading Partner Manual. This element is required for HMSA business needs. Do not use the following special pound sign (#), or caret symbol (^). NM108 Code PI or XV If HMSA is Other Payer use PI = Payer ID NM109 Other Payer Primary Identifier If HMSA is Other Payer use 990040115 (HMSA s Federal Tax ID) DTP 2330B Claim Check or Remittance Date REF 2330B Other Payer Secondary Identifier REF 2330B Other Payer Prior Authorization REF01 Reference G1 G1 = Treatment Authorization REF02 Prior Authorization Treatment Authorization Do not use the following special characters: Asterisk (*), equal sign (=), pound sign (#), or caret symbol (^). REF 2330B Other Payer Referral REF01 Reference 9F 9F = Referral REF02 Prior Referral Do not use the following special pound sign (#), or caret symbol (^). REF 2330B Other Payer Claim Adjustment Indicator REF 2330B Other Payer Claim Control 2330C Other Payer Attending Provider 7
NM1 2330C Other Payer Attending Provider REF 2330C Other Payer Attending Provider Secondary Identifier 2330D Other Payer Operating Physician NM1 2330D Other Payer Operating Physician REF 2330D Other Payer Operating Physician Secondary 2330E Other Payer Other Operating Physician NM1 2330E Other Payer Other Operating Physician REF 2330E Other Payer Other Operating Physician Secondary Identifier 2330F Other Payer Service Facility Location NM1 2330F Other Payer Service Facility Location REF 2330F Other Payer Service Facility Location Secondary 2330G Other Payer Rendering Provider Name NM1 2330G Other Payer Rendering Provider Name REF 2330G Other Payer Rendering Provider Secondary 2330H Other Payer Referring Provider NM1 2330H Other Payer Referring Provider REF 2330H Other Payer Referring Provider Secondary 2330I Other Payer Billing Provider NM1 2330I Other Payer Billing Provider REF 2330I Other Payer Billing Provider 2400 Service Line LX 2400 Service Line SV2 2400 Institutional Service Line SV201 Product/Service ID Revenue Codes must be submitted as a 4-position code. PWK 2400 Line Supplemental DTP 2400 Service Date REF 2400 Line Item Control REF 2400 Repriced Line Item Reference 8
REF 2400 Adjusted Repriced Line Item Reference AMT 2400 Service Tax Amount AMT 2400 Facility Tax Amount NTE 2400 Third Party Organization Notes HCP 2400 Line Pricing/Repricing 2410 Drug LIN 2410 Drug CTP 2410 Drug Quantity REF 2410 Prescription Or Compound Drug Association 2420A Operating Physician Name NM1 2420A Operating Physician Name REF 2420A Operating Physician Name 2420B Other Operating Physician Name NM1 2420B Other Operating Physician Name REF 2420B Other Operating Physician 2420C Rendering Provider Name NM1 2420C Rendering Provider Name REF 2420C Rendering Provider 2420D Referring Provider Name NM1 2420D Referring Provider Name REF 2420D Referring Provider 2430 Line Adjudication SVD 2430 Line Adjudication CAS 2430 Line Adjustment DTP 2430 Line Check or Remittance Date AMT 2430 Remaining Patient Liability SE Transaction Set Trailer GE Function Group Trailer IEA Interchange Control Trailer 9