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State Farm Insurance Companies Health Care Institutional: Paper Claims Implementation Guide

October 31st, 2007 1

Electronic Data Interchange Transaction Set Implementation Guide State Farm Insurance Companies 837 Health Care Institutional: Individual Health Paper Conversion and PPO Repricer ANSI ASC X12 Version 004010 Implementation Guide Version 1.2 October 31, 2007



Table of Contents 1. Purpose and Business Overview 1

1.1 Document Purpose .............................................................................................................................1 1.2 Version and Release ...........................................................................................................................1 1.3 Business Definition and Usage...........................................................................................................1 1.4 Contact Information ...........................................................................................................................1 1.5 Information Flow................................................................................................................................2

1.5.1 Information Flow of Institutional Non-Medicare Bills and Medicaid Bills 2 1.5.2 Information Flow of Institutional Medicare, Medigap, and 2 Medicare Summary Notice Bills. 2 1.5.3 Medical Bills Data Transfer 3

1 .6 Data Conversion (DC) ..............................................................................................................4 1.6.1 Submitter IDs 4 1.6.2 Eligibility Matching Process 4 1.6.3 Provider Matching Process 5

1.6.3.1 Billing Provider Matching Process: .................................................................................................................. 5 1.6.3.2 Pay To Provider Matching Process:.................................................................................................................. 6

1.6.4 Splitting Bills 6 1.6.5 Duplicate Medicare Bills 7 1.6.6. Medigap Carrier Information 7 1.6.7 Claim Adjustments 7 1.6.8 Claim Adjustment Code List 8 1.6.9 Data Entry Validation 8

2 Data Overview 9 2.1 Overall Data Architecture ..............................................................................................................9 2.2 Health Care Claim: Institutional bills.............................................................................................9 2.3 Note Usage .....................................................................................................................................9

2.3.1 Segment Situational Rules 9 2.3.2 Data Element Notes 10

2.4 Abbreviations ...............................................................................................................................11 2.5 Data Usage by Business Usage ....................................................................................................11

3 Transaction Set 12 3.1 Presentation Examples .................................................................................................................12 Implementation Table.............................................................................................................................20 837 Paper Claims Medical Bills: Institutional .......................................................................................20 Standard Table........................................................................................................................................22 837 Paper Claims Medical Bills:............................................................................................................22

ST TRANSACTION SET HEADER ........................................................................................................................ 25 BHT BEGINNING OF HIERARCHICAL TRANSACTION................................................................................ 26 NM1 SUBMITTER NAME ....................................................................................................................................... 28 NM1 RECEIVER NAME .......................................................................................................................................... 30 HL BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL......................................................................... 32 NM1 BILLING PROVIDER NAME ........................................................................................................................ 34 N3 BILLING PROVIDER ADDRESS ..................................................................................................................... 37 N4 BILLING PROVIDER CITY/STATE/ZIP CODE............................................................................................ 38 REF BILLING PROVIDER SECONDARY IDENTIFICATION......................................................................... 40 PER BILLING PROVIDER CONTACT INFORMATION.................................................................................... 42 NM1 PAY TO PROVIDER NAME .......................................................................................................................... 44 N3 PAY TO PROVIDER ADDRESS........................................................................................................................ 47 N4 PAY TO PROVIDER CITY/STATE/ZIP CODE.............................................................................................. 48 REF PAY TO PROVIDER SECONDARY IDENTIFICATION........................................................................... 50



HL SUBSCRIBER HIERARCHICAL LEVEL....................................................................................................... 52 SBR SUBSCRIBER INFORMATION ..................................................................................................................... 54 NM1 SUBSCRIBER NAME...................................................................................................................................... 56 REF SUBSCRIBER SECONDARY IDENTIFICATION ...................................................................................... 58 HL PATIENT HIERARCHICAL LEVEL .............................................................................................................. 60 PAT PATIENT INFORMATION............................................................................................................................. 62 NM1 PATIENT NAME ............................................................................................................................................. 64 N3 PATIENT ADDRESS........................................................................................................................................... 66 N4 PATIENT CITY/STATE/ZIP CODE ................................................................................................................. 67 DMG PATIENT DEMOGRAPHIC INFORMATION (DMG).............................................................................. 69 CLM CLAIM INFORMATION ............................................................................................................................... 71 DTP STATEMENT DATES...................................................................................................................................... 77 DTP ADMISSION DATE.......................................................................................................................................... 79 CL1 INSTITUTIONAL CLAIM CODE .................................................................................................................. 80 PWK CLAIM SUPPLEMENTAL INFORMATION.............................................................................................. 81 REF ADJUSTED REPRICED CLAIM NUMBER................................................................................................. 83 REF REPRICED CLAIM NUMBER....................................................................................................................... 85 REF VENDOR TRACE NUMBER .......................................................................................................................... 87 REF ORIGINAL REFERENCE NUMBER (ICN/DCN).......................................................................................... 89 NTE VENDOR NOTE ............................................................................................................................................... 91 HI PRINCIPAL ADMITTING E-CODE AND PATIENT..................................................................................... 93 REASON FOR VISIT DIAGNOSIS INFORMATION ............................................................................................ 93 HI OTHER DIAGNOSIS INFORMATION ............................................................................................................ 98 HI PRINCIPAL PROCEDURE INFORMATION ............................................................................................... 107 HI OTHER PROCEDURE INFORMATION ....................................................................................................... 110 HI OCCURRENCE INFORMATION ................................................................................................................... 117 HI VALUE INFORMATION.................................................................................................................................. 126 HCP CLAIM PRICING/REPRICING INFORMATION .................................................................................... 138 SBR OTHER SUBSCRIBER INFORMATION.................................................................................................... 142 CAS CLAIM LEVEL ADJUSTMENT .................................................................................................................. 144 AMT OTHER PAYER PRIOR PAID AMOUNT................................................................................................. 150 AMT COORDINATION OF BENEFITS (COB) TOTAL ALLOWED AMOUNT ....................................... 151 AMT COORDINATION OF BENEFITS (COB) TOTAL MEDICARE PAID AMOUNT .............................. 152 AMT COORDINATION OF BENEFITS (COB) TOTAL ................................................................................... 153 NON-COVERED AMOUNT..................................................................................................................................... 153 MIA MEDICARE INPATIENT ADJUDICATION INFORMATION ............................................................... 154 NM1 OTHER PAYER NAME ................................................................................................................................ 158 REF OTHER PAYER (MEDICARE) SECONDARY IDENTIFICATION AND REFERENCE NUMBER (ICN/DCN) .................................................................................................................................................................. 160 LX SERVICE LINE NUMBER .............................................................................................................................. 162 SV2 INSTITUTIONAL SERVICE LINE .............................................................................................................. 163 DTP SERVICE LINE DATE................................................................................................................................... 167 HCP LINE PRICING/REPRICING INFORMATION ........................................................................................ 168 SE TRANSACTION SET TRAILER ..................................................................................................................... 172

A X12 Nomenclature 173 A.1 Interchange and Application Control Structures ....................................................................... 173

A.1.1 Interchange Control Structure 173 Figure A1. Transmission Control Schematic 175

A.1.2 Application Control Structure Definitions and Concepts...................................................................... 175 A.1.2.1 Basic Structure 175 A.1.2.2 Basic Character Set 175 A.1.2.3 Extended Character Set 175 A.1.2.4 Control Characters 176 A.1.2.5 Base Control Set 176 A.1.2.6 Extended Character Set 176 A.1.2.7 Delimiters 177



A.1.3 Business Transaction Structure Definitions and Concepts .................................................................... 177

A.1.3.1 Data Element 177 A.1.3.1.1 Numeric 178 A.1.3.1.2 Decimal 178 A.1.3.1.3 Identifier 179 A.1.3.1.4 String 179 A.1.3.1.5 Date 179 A.1.3.1.6 Time 179

A.1.3.2 Composite Data Structure ........................................................................................................................ 179 A.1.3.3 Data Segment ............................................................................................................................................. 179 A.1.3.4 Syntax Notes............................................................................................................................................... 179 A.1.3.5 Semantic Notes........................................................................................................................................... 180 A.1.3.6 Comments................................................................................................................................................... 180 A.1.3.7 Reference Designator ................................................................................................................................ 180 A.1.3.8 Condition Designator ................................................................................................................................ 181 A.1.3.9 Absence of Data ......................................................................................................................................... 182 A.1.3.10 Control Segments........................................................................................................................................ 182

A.1.3.10.1 Loop Control Segments 182 A.1.3.10.2 Transaction Set Control Segments 182 A.1.3.10.3 Functional Group Control Segments 182 A.1.3.10.4 Relations among Control Segments 183

A.1.3.11 Transaction Set ...................................................................................................................................... 183 A.1.3.11.1 Transaction Set Header and Trailer 183 A.1.3.11.2 Data Segment Groups 183 A.1.3.11.3 Repeated Occurrences of Single Data Segments 183 A.1.3.11.4 Loops of Data Segments 183

A.1.3.11.4.1 Unbounded Loops 184 A.1.3.11.4.2 Bounded Loops 184

A.1.3.11.5 Data Segments in a Transaction Set 184 A.1.3.11.6 Data Segment Requirement Designators 184 A.1.3.11.7 Data Segment Position 184 A.1.3.11.8 Data Segment Occurrence 184

A.1.3.12 Functional Group .................................................................................................................................. 184 A.1.4 Envelopes and Control Structures 185

A.1.4.1 Interchange Control Structures ............................................................................................................... 185 A.1.4.2 Functional Groups..................................................................................................................................... 185

A.1.5 Acknowledgments 186 A.1.5.1 Interchange Acknowledgment, TA1 ........................................................................................................ 186 A.1.5.2 Functional Acknowledgment, 997 ............................................................................................................ 186

B EDI Control Directory 187 B.1 Control Segments .......................................................................................................................187

ISA INTERCHANGE CONTROL HEADER 188 IEA INTERCHANGE CONTROL TRAILER 191 GS FUNCTIONAL GROUP HEADER 192 GE FUNCTIONAL GROUP TRAILER 194 TA1 INTERCHANGE ACKNOWLEDGMENT 195

B.2 Functional Acknowledgment Transaction Set, 997 ...................................................................198 997 Functional Acknowledgment 198

ST Transaction Set Header....................................................................................................................................... 200 AK1 Functional Group Response Header ............................................................................................................... 201 AK2 Transaction Set Response Header................................................................................................................... 202 AK3 Data Segment Note ............................................................................................................................................ 203 AK4 Data Element Note............................................................................................................................................ 205 AK5 Transaction Set Response Trailer ................................................................................................................... 207 AK9 Functional Group Response Trailer................................................................................................................ 209 SE Transaction Set Trailer ....................................................................................................................................... 211



C Code Lists and External Code Sources 212

4 ABA Routing Number ..................................................................................................................... 212 5 Countries, Currencies and Funds ..................................................................................................... 212 22 States and Outlying Areas of the U.S. ........................................................................................... 213 51 ZIP Code........................................................................................................................................ 213

D Change Summary 2143 E Example 2154

State Farm Insurance Companies Health Care Paper Claims: Institutional Implementation Guide

October 31, 2007 1

1. Purpose and Business Overview

1.1 Document Purpose

The purpose of the 837 Health Care Claim: Institutional implementation guide is to provide standardized data requirements and content to all users of ASC X12, Institutional Health Care Claim referred to by its identifier 837. The guide provides a detailed explanation of 837 transaction set by defining uniform data content and identifying valid code tables and specifying values applicable for Health Care Claim Data (Institutional). This guide will aid trading partners such as Data Conversion vendors, Re-Pricers and etc to understand State Farm business requirements and adhere to the EDI format based on ASC X12 standards. This implementation guideline is designed to assist primarily those trading partners who will be sending Health Care Claim data converted from Paper Bills to EDI format to State Farm Insurance Companies. Expected users of this implementation guide includes State Farm Insurance Companies, Data Conversion Vendors, Claim Re-Pricers and the Health Claim Trading Partners such as claim intermediaries that does business with State Farm Insurance Companies. This implementation guide is limited to the data content of the business requirements identified from the Claim Adjudication, Re-pricing procedures and other State Farm internal business systems. The ability to satisfy the data requirements has been provided in this guide. Contact State Farm as new business requirements are being identified and changes to this implementation guide are required. .

1.2 Version and Release The State Farm Insurance Companies Health Care Claim Institutional Implementation Guide is based on ASC X12 standards. It is based on the standard approved for publication in October of 1997, referred to as Version 4 Release 1 (004010).

1.3 Business Definition and Usage The X12 837 transaction set is used by State Farm Insurance Companies to receive Institutional claims and/or encounters. This implementation guide provides standardized data requirements and content for trading partners of the 837 doing business with State Farm. The purpose of this implementation guide is to expedite the goal of achieving a totally electronic data interchange for this transaction between different trading partners and State Farm. This implementation guide provides a definitive statement of what data the application systems must be able to handle in order to process the information sent by the individual medical providers and health care institutions. The implementation guide also specifies limits and guidance to what a provider (submitter) can place in an 837. The 837 Institutional transaction set is used by State Farm Insurance Companies to receive health encounter and health claim data from health care providers such as doctors and medical institutions via claim intermediaries or clearinghouses. All State Farm Insurance Companies health care bills are included in this 837 transmission file for both Medicare and Non-Medicare. Currently State Farm will only be accepting 837 transmission file that contains one claim loop for each claim originally submitted by the medical provider. The 837 transmission file will be generated by the claim intermediaries for the bills generated by health-care providers and transmitted to State Farm Insurance Companies on a daily basis. These incoming 837 X12 files are translated and then are used to update the internal systems. Outbound 837 files are also generated for re-pricing purposes based on this implementation guide and 835 transactions are also generated for electronic remittance. This implementation guide will also be used by Data Conversion Vendors to convert the data from paper bills to ANSI X12 EDI format. The DC (Data Conversion) trading partners will adhere to the requirements of this implementation guide for all business purposes unless specified by State Farm.

1.4 Contact Information To contact State Farm about this guide or a production problem with the implementation of this guide call 1 (877) 766-6371. Your call can be answered by voice menu that will give you two options. Choose the option for "Corporate Employees" and stay on the line. When a representative answers, request help with "EDI (Electronic Data Interchange) ". They will route your call to someone who will assist you.


October 31, 2007 2

1.5 Information Flow 1.5.1 Information Flow of Institutional Non-Medicare Bills and Medicaid Bills 1.5.2 Information Flow of Institutional Medicare, Medigap, and

Medicare Summary Notice Bills.

PPO (Re-Prices) (3)

Data (1) Conversion Vendor

State Farm (2) Insurance Companies

Automatic (4) Claims Adjudication

Health (5) Interactive Claims Systems

Data Conversion Vendor

State Farm Insurance Companies

Automatic Claims Adjudication

Health Interactive Claims Systems


October 31, 2007 3

1.5.3 Medical Bills Data Transfer

Claim Intermediary /

Clearinghouse / Data Conversion

Vendor

State Farm Insurance

Companies

Providers/ Medical

Institutions

Re-pricing Vendor

This Implementation Guide will be used by Clearing houses who wish to submit 837 claims in electronic format or by Data Conversion trading partners in order to convert data from paper bills to EDI X12 837 format. Data Conversion will help create a work flow process to provide a means of electronically submitting claim payments and remittance information to health providers that may send paper bills.

835 Remittance Advice

837

835

835835


October 31, 2007 4

1.6 Data Conversion (DC) This Implementation Guide will be used by Data Conversion trading partner to convert data from paper bills to EDI X12, 837 format. Data Conversion will help to create a work flow process to provide a means of electronically submitting claim payments and remittance information to health care providers who send paper bills. 1.6.1 Submitter IDs State Farm requires separate submitter IDs to distinguish data converted EDI bill types. Submitter IDs in Loop 1000A NM109 are required for the following bill types:

1.6.2 Eligibility Matching Process The Data Conversion (DC) vendor will key data from imaged documents to match against an eligibility file provided by State Farm. The eligibility file will be sent to the DC vendor weekly. If a match is located, the DC vendor will populate the following information into the 837 from the eligibility file:

X12 Element Eligibility File Field Notes 2010BA NM103 – Subscriber Last Name HAAQQ_LAST_NAME 2010BA NM104 – Subscriber First Name HAAQQ_FIRST_NAME 2010BA NM105 – Subscriber Middle Name HAAQQ_MIDDLE_INITIAL MAY BE BLANK 2010BA NM109 – Subscriber ID Code HAAQQ_POLICY_NUMBER 2010CA NM103 – Patient Last Name HAAQQ_LAST_NAME 2010CA NM104 – Patient First Name HAAQQ_FIRST_NAME 2010CA NM105 – Patient Middle Name HAAQQ_MIDDLE_INITIAL MAY BE BLANK 2010CA N301 – Patient Address1 HAAQQ_STREET_ADDRESS_1 2010CA N302 – Patient Address2 HAAQQ_ STREET_ADDRESS_2 MAY BE BLANK 2010CA N401 – Patient City HAAQQ_CITY 2010CA N402 – Patient State HAAQQ_STATE 2010CA N403 – Patient postal Code HAAQQ_ZIP 2010CA DMG02 – Patient Birth Date HAAQQ_DATE_OF_BIRTH 2010CA DMG03 – Patient Gender Code HAAQQ_GENDER

Bill Type Submitter Id Non-Medicare (Professional & Institutional) XXXXXXXXX Medicare (Professional & Institutional) XXXXXXXXXM Medicaid (Professional & Institutional) XXXXXXXXXC Medicare Summary Notice (Professional & Institutional) XXXXXXXXXS Medigap (Professional) XXXXXXXXXG Other Non-Medicare (Professional & Institutional) XXXXXXXXX1 Other Medicare (Professional & Institutional) XXXXXXXXX2 Other Medicaid (Professional & Institutional) XXXXXXXXX5 Other Medigap (Professional) XXXXXXXXX3 Other Medicare Summary Notice (Professional & Institutional) KEY_TIN_NO


October 31, 2007 5

1.6.3 Provider Matching Process The Data Conversion (DC) vendor will key data from imaged documents to match against a provider file created by State Farm. The provider file will be sent to the DC vendor daily. If a match is located, the DC vendor will populate the 837 from the provider file. If a match is not located in this file, the DC vendor will key the provider information from the image. The DC vendor will send a daily file to State Farm that contains new TIN’s and the associated provider information. The DC vendor will not send the same TIN/provider information multiple times in the daily file to State Farm. The DC vendor will employ this provider matching process for the 2010AA Billing Provider and 2010AB Pay-to Provider loops. The 837 2010AA and 2010AB loops will be populated from the State Farm Provider File according to the following tables:

1.6.3.1 Billing Provider Matching Process:

X12 Element Billing Provider File Field Notes 2010AA NM102 – Billing Provider Qualifier 1 or 2,

see note If HAAPZ_NAMETYPE =C, CLINIC (Non-Individual) then NM102 = 2 If HAAPZ_NAMETYPE =I, INDIVIDUAL then NM102 = 1

2010AA NM103 – Billing Provider Last Name HAAPZ_NAME1 PROVIDER NAME LINE 1 WHEN HAAPZ_NAMTYPE = ‘C’ ENTIRE LINE IS USED FOR NON-INDIVIDUAL NAME. WHEN HAAPZ_NAMTYPE = ‘I’ POS 1-15 ARE LAST NAME, POS 16-29 ARE FIRST NAME, POS 30 IS MIDDLE INITIAL. If NM102 = 2, then only NM103 is sent If NM103 = 1, then NM103 and NM104 are sent

2010 AA NM104 - Billing Provider First Name

HAAPZ_NAME1 See 2010AA NM103 note

2010 AA NM108 - Identification Code Qualifier

24 or 34, see note

IF HAAPZ_TINTYPE = T then NM108 = 24 IF HAAPZ_TINTYPE = S the NM108 = 34

2010 AA NM109 – Identification Code HAAPZ_TIN 2010AA N301 – Billing Provider Address1 HAAPZ_ADDR1 2010AA N302 – Billing Provider Address2 HAAPZ_ADDR2 2010AA N401 – Billing Provider City HAAPZ_CITY 2010AA N402 – Billing Provider State HAAPZ_ST 2010AA N403 – Billing Provider postal Code HAAPZ_ZIP 2010 AA PER04 – Billing Provider Contact

Information HAAPZ_WORK_PHONE PER03 must be TE


October 31, 2007 6

1.6.3.2 Pay To Provider Matching Process:

X12 Element Pay To Provider File Field Notes 2010AB NM102 – Pay to Provider Qualifier 1 or 2,

see note If HAAPZ_NAMETYPE =C, CLINIC (Non-Individual) then NM102 = 2 If HAAPZ_NAMETYPE =I, INDIVIDUAL then NM102 = 1

2010AB NM103 – Pay to Provider Last Name HAAPZ_NAME1 PROVIDER NAME LINE 1 WHEN HAAPZ_NAMTYPE = ‘C’ ENTIRE LINE IS USED FOR NON-INDIVIDUAL NAME. WHEN HAAPZ_NAMTYPE = ‘I’ POS 1-15 ARE LAST NAME, POS 16-29 ARE FIRST NAME, POS 30 IS MIDDLE INITIAL. If NM102 = 2, then only NM103 is sent If NM103 = 1, then NM103 and NM104 are sent

2010 AB NM104 - Pay to Provider First Name

HAAPZ_NAME1 See 2010AA NM103 note

2010 AB NM108 - Identification Code Qualifier

24 or 34, see note

IF HAAPZ_TINTYPE = T then NM108 = 24 IF HAAPZ_TINTYPE = S the NM108 = 34

2010 AB NM109 – Identification Code HAAPZ_TIN 2010AB N301 – Pay To Provider Address1 HAAPZ_ADDR1 2010AB N302 – Pay To Provider Address2 HAAPZ_ADDR2 2010AB N401 – Pay To Provider City HAAPZ_CITY 2010AB N402 – Pay To Provider State HAAPZ_ST 2010AB N403 – Pay To Provider postal Code HAAPZ_ZIP

State Farm expects the following segments: Institutional Bill: State Farm expects the 2010AA loop always. Institutional Medicaid Bill: State Farm expects the 2010AA loop and 2010AB loop always. 1.6.4 Splitting Bills The data conversion vendor will split the following documents into multiple bills:

o Medicare Summary Notices with multiple ICN/DCNs. Each ICN/DCN is a separate bill. o Medicare bills with multiple ICN/DCNs. Each ICN/DCN is a separate bill. o Non-Medicare professional bills exceeding 50 lines.


October 31, 2007 7

1.6.5 Duplicate Medicare Bills For all Medicare bill types except Medicare Summary Notice, the data conversion vendor will key the ICN/DCN number from the Medicare EOB to match against an ICN/DCN data table we provide on a daily basis. When a match is found the bill will be rejected back to State Farm and will not be converted. Bills without a match will continue through the conversion process. For Medicare Summary Notice (MSN) bill types, the data conversion vendor will key the ICN/DCN number from the MSN to match against the ICN/DCN data table we provide on a daily basis. If a match is found, minimal data will be keyed from the bill. Default values will be utilized for the remaining required data segments. Also, the data conversion vendor will retain Medigap carrier information on duplicate Medigap bills. 1.6.6. Medigap Carrier Information The data conversion vendor will retain the following information for each Medigap carrier on Medigap bills:

o Number of Medigap bills received o Number of Medigap bills converted o Number of Medigap ICN duplicates o Number of Medigap Invalid policy rejections o Number of Medigap other rejections (all other types of rejections)

Month to date and year to date data will be provided in a monthly Data Conversion Medigap report. 1.6.7 Claim Adjustments The Data Conversion vendor will key claim adjustment data from the Medicare EOB, Medicare Summary Notice (MSN) and Medigap form. All adjustments will be included in the Claim Level CAS Loop 2320. Claim adjustments may appear on the paper forms under the following heading or names.

o “GRP/RC AMT” o “Contract adj” o “Cont adj amt” o “Claim adj“ o “Line adj amt” o “Deductible” o “Coinsurance” o “Blood deductible”


October 31, 2007 8

1.6.8 Claim Adjustment Code List

1.6.8.1. Claim Adjustment Group Codes for CAS01 in Loop 2320

CODE DEFINITION CO Contractual Obligations OA Other Adjustments CR Corrections and Reversals PI Payer Initiated Reductions PR Patient Responsibility

Key the value present on the paper form. Otherwise, default to value PR for deductible, coinsurance and blood deductible or default to value CO for all other adjustments.

1.6.8.2. Claim Adjustment Reason Codes (code list 139) for CAS02, CAS05 etc in Loop 2320

Data Conversion vendor keys codes that are present on the form and utilizes the following codes for un-coded adjustments.

CODE DEFINITION 1 Deductible 2 Coinsurance 66 Blood Deductible A2 Contractual adjustment

Default to value A2 for all other adjustments.

1.6.9 Data Entry Validation The data conversion vendor will validate the following data:

o Double key 2300 DTP02 Statement Dates for all bill types except Medicare Summary Notice duplicate ICN bills. o Double key 2330B REF02 ICN/DCN for all Medicare and Medicare Summary Notice bills o Key 2300 CLM02 Total Charges and compare to calculated total of all line level charges if available. If the totals

do not balance and no critical default values of zero exist for charge line level amounts, double key line level charges and default to line level total. If the totals do not balance and any live level amounts are critical default values of zero, default to Total Charge amount on bill.

o Compare any A1, B1 or C1 2300H102-1 Value Code amounts to 2320 CAS01 amounts for deductible (PR1). If

the totals do not balance double key 2320CAS01 deductible amounts from the EOB. If still unbalanced set value code amount to zero and enter UB Ded note in 2300 NTE02. Use critical default value if value for 2320CAS01 amount is illegible.

o Compare any A2, B2, C2, 09 or 11 2300H102-1 Value Code amounts to 2320 CAS01 amounts for coinsurance

(PR2). If the totals do not balance double key 2320CAS01 coinsurance amounts from the EOB. If still unbalanced, set value code amount to zero and enter “UB Coin”s note in 2300 NTE02. Use critical default value if value for 2320CAS01 amount is unavailable or illegible.

o Quality checks if both PR1 and PR2 equals to zero on Medicare, Medicare Summary Notice and Medigap bills.


October 31, 2007 9

2 Data Overview 2.1 Overall Data Architecture

• NOTE For a review of transaction set structure, including descriptions of segments, data elements, levels and loops, see Appendix A, ASC X12 Nomenclature.

2.2 Health Care Claim: Institutional bills

The Health Care Paper Claim: Institutional implementation of the 837 is used to update State Farm Insurance Companies, internal health billing systems and also used by processes such as Automatic Claims Adjudication (ACA) and re-pricing systems. This is accomplished by receiving an 837transmission file from the trading partners, claim intermediaries and from Data Conversion vendors. These records are then matched to the internal invoice database and records are updated accordingly. The Non-Medicare claims which need to be re-priced by State Farm are sent to a re-pricing vendor in the 837 format, who then after re-pricing sends those bills in 837 format with the additional segments.

2.3 Note Usage There are segment level notes and element level notes mentioned in this guide to provide more detailed information to the trading partner about the usage of that segment/element.

2.3.1 Segment Situational Rules

Segment Situational Rules are used any time a segment is Situational. The Situational Rule defines the condition that requires the inclusion of the segment. Situational Rules1: Required, if necessary, to meet specific trading partner data requirements. This Situational Rule is used when a segment is needed to carry specific data required by a receiving Trading Partner. These segments are generally used by PPO re-pricing Vendors. The specific Trading Partner data requirements are not documented in this Implementation Guide. This Situational Rule is never used if the data in the segment is a State Farm requirement. Situational Rules2: Required, when, a secondary identification number is necessary to identify the entity. The primary identification number must be carried in the NM109. This Situational Rule is used when more than one identification number is available. The primary identification number must be sent in the corresponding NM109 of the Loop. Situational Rules3: Required when the Trading Partner has a need to identify any problems or issues encountered in the data conversion process. This Situational Rule is used when problems are encountered in the data conversion process. The conditions that require the reporting of these notes are documented both in the NTE02 element notes, and other supporting documents.


October 31, 2007 10

Situational Rules4: Required when there are appropriate values that apply to this claim, and those values are legible. If not present or legible, do not send. This Situational Rule is used when segments exist, and that carry supporting data that may or may not be available. Situational Rules5: Required for all Medicare claims, when the data is necessary for adjudication., This Situational Rule is used when the data within a segment is expected to be included on a Medicare Claim and that data is necessary in the adjudication process.

2.3.2 Data Element Notes Data Element Notes are used to provide details and direction on the usage of specific data elements. The notes documented below are not an all inclusive list of all the data element notes used in this Implementation Guide. They are however, representative of those notes used most frequently. Element Rule 1: This element is critical to application processing. This note is used whenever a value is critical to application processing. Element Rule 2: Defaults to value “xx” This note is used whenever a value must be present in the data element. The note identifies the default value represented by xx. Element Rule 3: Paper Form Equivalent: UB BOX #xx This note is used whenever a reference is made to a specific location on a paper format. The UB Box number is represented by xx. Element Rule 4: Required, if present on the paper form, If not present, or the value is not legible, do not send. This note is used whenever an element is situational, and is not critical, and/or there is no default value. The value must be submitted if it is present and legible on the paper format. Element Rule 5: This element is derived from eligibility check process. This note is used whenever an element is derived from the eligibility check process.


October 31, 2007 11

2.4 Abbreviations

No. Code Description 1. EOB Medicare Explanation of Benefits 2. Aka Also Known As 3. MSN Medicare Summary Notice 4 NPI National Provider Identification 5 UB Uniform Billing 6 ICN/DCN Internal Control Number/Document Control Number 7 ICD International Classification of Diseases 8 CPT Common Procedure Terminology 9 HCPCS Health Care Financing Common procedure coding System 10 CMS Centers for Medicare and Medicaid (Formally HCFA) 11 PPO Preferred provider organization 12 TPO Third party Organization 13 DRG Diagnosis Related Group 14 GRP/RC Group/Reason Code 15

2.5 Data Usage by Business Usage

The 837transaction is divided into three tables, Table 1 (Header), Table 2 (Detail), and Table 3 (Summary). See Section 3, Transaction Set, for a description of the following presentation format.

• Table 1, the Header level, contains general information about the transaction sender and receiver.

• Table 2, the Detail- level, contains information about the Billing Provider, Subscriber and Patient.

• Table 3, the Summary level, contains the transaction set trailer which contains a segment count and control

number.


October 31, 2007 12

3 Transaction Set

• NOTE For a review of the transaction set structure including descriptions of segments, data elements, levels and loops, see Appendix A, ASC X12 Nomenclature.

3.1 Presentation Examples

The ASC X12 standards are generic in nature. For example, multiple trading communities use the same PER segment to specify administrative communication contacts. Each community decides which elements to use and which code values in those elements are applicable. This guide uses a format that depicts both the generalized standard and the State Farm Insurance Company's specific implementation.

The transaction set detail is comprised of two main sections with subsections within the main sections:

• Transaction Set Listing

• Implementation • Standard

• Segment Detail

• Implementation • Standard • Diagram • Element Summary

The examples in Figures 3 through 8 define the presentation of the Transaction set. To show how to interpret the presentation of this format an 834 transaction set is described in figures and is as follows.


October 31, 2007 13

IMPLEMENTATION

Indicates that this section is how State Farm Insurance Companies is implementing the transaction/segment and not the standard

834 Benefit Enrollment and Maintenance Functional Group: BE

Table 1 – Header

Each segment is assigned State Farm specific name. Segments or loops that aren't used do not appear. Each loop (shaded in gray) is assigned a State Farm specific name as well.

POS.NO.

SEG.ID

NAME

REQ.DES.

MAX USE

LOOP REPEAT

010

ST

Transaction Set Header

R 1

020 BGN

Beginning of Dental Eligibility Data

R 1

LOOP ID - 1000 1

070 N1

Sender Name

R 1

090 N3

Sender Address

O 1

100 N4

Sender City, State and Zip

O 1

Sender Contact Information

O 1

Position Numbers and Segment ID's retain their ASC X12 values

R = Required O = Optional

Segment repeats and loop repeats reflect actual usage. Individual segments and entire loops are repeated if the business needs require it

Figure 3. Transaction Set Key – IMPLEMENTATION


October 31, 2007 14

STANDARD

Indicates that this section is identical to the ASC X12 standard See Appendix A, ASC X12 Nomenclature for a complete description of the standard

834Benefit Enrollment and Maintenance Functional Group: BE This Draft Standard for Trial Use contains the format and establishes the data contents of the Benefit Enrollment and Maintenance Transaction Set (834) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to establish communication between the sponsor of the insurance product and the payer. Such transaction(s) may or may not take place through a third party administrator (TPA).

For the purpose of this standard, the sponsor is the party or entity that ultimately pays for the coverage, benefit or product. A sponsor can be an employer, union, government agency, association, or insurance agency.

The payer refers to an entity that pays claims, administers the insurance product or benefit, or both. A payer can be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, CHAMPUS, etc.), or an entity that may be contracted by one of these former groups.

For the purpose of the 834 transaction set a third party administrator (TPA) can be contracted by a sponsor to handle data gathering from those covered by the sponsor if the sponsor does not elect to perform this function itself.

Table 1 – Header

POS. NO.

SEG. ID

NAME

REQ.DES.

MAX USE

LOOP REPEAT

010

ST


M 1

020 BGN

Beginning Segment

M 1

030 REF

Reference Identification

O >1

040 DTP

Date or Time or Period

O >1

050 AMT

Monetary Amount

O >1

Figure 4. Transaction Set Key – STANDARD


October 31, 2007 15

IMPLEMENTATION

State Farm assigned Segment Name

SUBSCRIBER'S COVERAGE CODE

State Farm assigned Loop Name and Loop Repeat

Loop: SUBSCRIBER Repeat: 1

State Farm assigned Usage and Segment Repeat values Usage: REQUIRED Repeat: 1

Notes are entered by State Farm to further clarify how a segment or element within the segment is used

Notes: 1. This segment will contain the Subscriber's Coverage Code. 2. REF01 will be coded as "D7" to indicate "Coverage Code". Example: REF*D7*12HM5J~

Example of how the segment is used based on how each element is defined within the Element Summary section

Figure 5. Segment Key – IMPLEMENTATION


October 31, 2007 16

STANDARD

REF Reference Identification X12 Segment ID and Name X12 Segment Level and Position within the Transaction Set

Level: Detail. Position: 020 Loop: 2000 Repeat: >1

X12 Loop Identifier and Loop Repeat value

Requirement: Optional X12 Segment Requirement

Max Use: >1

X12 Maximum Use of the segment

Purpose: To specify identifying numbers.

Purpose of the X12 segment as it is defined by the X12 standards

Syntax: 02 R0203 At least one of REF02 or REF03 is required.

04 P0304 If either REF04-3 or REF04-4 is present, then the other is required.

04 P0506 If either REF04-5 or REF04-6 is present, then the other is required. X12 Syntax Notes and Semantic Notes for the elements within the segment as defined by the X12 standard

Semantic: 04 REF04 contains data relating to the value cited in REF02

Figure 6. Segment Key - STANDARD


October 31, 2007 17

DIAGRAM

Indicates the element Number/Sequence Number of the element within the segment

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

REF01

128

Reference Identification Qualifier

R 2/3

M ID 2/3

REF02

127

Reference Identification

R 1/30

X AN 1/30

REF03

352

Description

NU

X AN 1/80

REF04

C040

Reference Identifier

NU

O/Z

Indicates what the Element ID is that defines what the element is and how it is to be used

Indicates whether or not the specific element is Required (R), Optional (O), or Not Used (NU) by State Farm. It also identifies the min and max lengths that State Farm can accept in the data element.

This section is made up of three distinct pieces. All of the information contained in this box is based on the actual X12 standard for the segment. The first piece of information on the far left is called the "Requirements Designator". This piece is based upon the X12 standards for the segment whereas The "SF Req." box to the immediate left indicates requirements based on State Farm's needs. The designators used here are Mandatory (M), Optional (O) and Relational (X). If a "Z" follows the Requirements Designator, that indicates a Semantic Note is available to identify what the intended use of the element is. The semantic note on the element can be found in the STANDARDS section. The information in the center is the Data Type of the element. The information on the right side indicates what the minimum and maximum lengths are for the data element.

Figure 7. Segment Key – DIAGRAM


October 31, 2007 18

ELEMENT SUMMARY

Reference Designator (Element) and its corresponding Element Name and Description from the X12 Standards

REF01 Reference Identification Qualifier Code Qualifying the Reference Identification

This element will contain the Reference Identification Qualifier which qualifies the information found in REF02 that follows.

CODE DEFINITION D7 Coverage Code

List of valid codes and their corresponding definition(s) are to be used in this occurrence of the particular segment and element. Codes outside of this list will not be used. Only the ones listed can and will be used.

REF02 Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

This element will contain the Coverage Code

REF03 Description A free-form description to clarify the related data elements and their content

If used, this element will contain a further description of the coverage code that is found in REF02.

REF04 Reference Identifier

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier This element is not used by State Farm

Lines in bold after each element and the Element's description are notes from State Farm that help explain our use (or non-use) of the data element.

Figure 8. Segment Key - ELEMENT SUMMARY


October 31, 2007 19

This completes section 3.1which explains the format that is used starting on the next page. The actual implementation guide for process follows:


October 31, 2007 20

Implementation Table 837 Paper Claims Medical Bills: Institutional

Table 1.Header

POS # SEG ID NAME REQ. DES

MAX USE

LOOP REPEAT

005 ST Transaction Set Header R 1 010 BHT Beginning of Hierarchical Transaction R 1

LOOP ID – 1000A SUBMITTER NAME 1 020 NM1 Submitter Name R 1

LOOP ID –1000B RECEIVER NAME 1 020 NM1 Receiver Name R 1

Table 2.Detail, Billing-To Provider Hierarchical Level

POS SEG

ID NAME REQ

DES MAX USE

LOOP REPEAT

LOOP ID – 2000A – BILLING/PAY TO PROVIDER HIERARCHICAL LEVEL

>1

001 HL Billing/Pay to Provider Hierarchical Level R 1

LOOP ID – 2010AA BILLING PROVIDER NAME 1 015 NM1 Billing Provider Name R 1 025 N3 Billing Provider Address R 1 030 N4 Billing Provider City/State/ZIP Code R 1 035 REF Billing Provider Secondary Identification S 1 045 PER Billing Provider Contact Information S 1 LOOP ID – 2010AB PAY TO PROVIDER NAME 1 015 NM1 Pay To Provider Name S 1 025 N3 Pay To Provider Address S 1 030 N4 Pay To Provider City/State/ZIP Code S 1 035 REF Pay To Provider Secondary Identification S 1

Table 2. Detail Subscriber Hierarchical Level

POS SEG DES

NAME REQ DES

MAX USE

LOOP REPEAT

LOOP ID 2000B SUBSCRIBER HIERARCHICAL LEVEL >1 001 HL Subscriber Hierarchical Level R 1 005 SBR Subscriber Information R 1

LOOP ID 2010BA SUBSCRIBER NAME 1 015 NM1 Subscriber Name R 1 035 REF Subscriber Secondary Identification S 1 Table 2. Detail Patient Hierarchical Level

LOOP ID – 2000C PATIENT HIERARCHICAL LEVEL >1 001 HL Patient Hierarchical Level R 1 007 PAT Patient Information S 1 LOOP ID 2010CA PATIENT NAME 1 015 NM1 Patient name R 1 025 N3 Patient Address R 1 030 N4 Patient City/State/ZIP Code R 1 032 DMG Patient Demographic Information (DMG) R 1


October 31, 2007 21

LOOP ID 2300 CLAIM INFORMATION 100 130 CLM Claim Information R 1 135 DTP Statement Dates R 1 135 DTP Admission Date/Hour S 1 140 CL1 Institutional Claim Code R 1 155 PWK Claim Supplemental Information S 1 180 REF Adjusted Re-Priced Claim Number S 1 180 REF Re-Priced Claim Number S 1 180 REF Vendor Trace Number S 1 180 REF Original Reference Number (ICN\DCN) S 1 190 NTE Vendor Note S 10 231 HI Principal Admitting, E-Code and Patient Reason for Visit Diagnosis

Information R 1

231 HI Other Diagnosis Information S 2 231 HI Principal Procedure Information S 1 231 HI Other Procedure Information S 2 231 HI Occurrence Information S 1 231 HI Value Information S 2 241 HCP Claim Pricing / Re-Pricing Information S 1

LOOP ID – 2320 OTHER SUBSCRIBER INFORMATION 10 290 SBR Other Subscriber Information S 1 295 CAS Claims Level Adjustment S 5 300 AMT Other Payer Paid Amount S 1 300 AMT COB Total Allowed Amount S 1 300 AMT COB Total Medicare Paid Amount S 1 300 AMT COB Total Non-Covered Amount S 1 315 MIA Medicare In-Patient Adjudication Information S 1

LOOP ID 2330B OTHER PAYER NAME 1 325 NM1 Other Payer Name S 1 355 REF Other Payer (Medicare) Secondary Identification and Reference Number

(ICN/DCN) S 2

LOOP ID –2400 SERVICE LINE NUMBER 999 365 LX Service Line Number R 1 375 SV2 Institutional Service Line Number R 1 455 DTP Service Line Date R 1 492 HCP Line Pricing/ Re-Pricing Information – As Per Addenda S 1

555 SE Transaction Set Trailer R 1


October 31, 2007 22

Standard Table

837 Paper Claims Medical Bills: Table 1 – Header

POS# SEG ID. NAME REQ DES MAX USE LOOP REPEAT

005 ST Transaction Set Header M 1

010 BHT Beginning of Hierarchical Transaction M 1

015 REF Reference Identification O 3

LOOP ID – 1000 10

020 NM1 Individual or Organization name O 1

025 N2 Additional Name Information O 2

030 N3 Address Information O 2

035 N4 Geographic Information O 1


045 PER Administrative Communications Contact O 2

Table 2 -- Detail

POS# SEG ID. NAME REQ DES MAX USE LOOP REPEAT

LOOP ID – 2000 >1

001 HL Hierarchical Level M 1

003 PRV Provider Information O 1

005 SBR Subscriber Information O 1

007 PAT Patient Information O 1

009 DTP Date or Time or Period O 5

010 CUR Currency O 1

LOOP ID 2010 10





032 DMG Demographic Information (DMG) O 1

035 REF Reference: Identification O 20

040 PER Administrative Communication Contact O 2

LOOP ID 2300 100

130 CLM Health Claim O 1


140 CL1 Claim Codes O 1

145 DN1 Orthodontic Information O 1

150 DN2 Tooth Summary O 35

155 PWK Paper Work O 10

160 CN1 Contract Information O 1

165 DSB Disability Information O 1

170 UR Peer Review Organization or Utilization Review O 1

175 AMT Monetary Amount O 40


185 K3 File Information O 10

190 NTE Note/Special Instruction O 20

195 CR1 Ambulance Certification O 1

200 CR2 Chiropractic Certification O 1

205 CR3 Durable Medical Equipment Certification O 1

210 CR4 Enteral or Parenteral Therapy Certification O 3

215 CR5 Oxygen Therapy Certification O 1

216 CR6 Home Health Care Certification O 1

219 CR8 Pacemaker Certification O 1

220 CRC Conditions Indicator O 100

231 HI Health Care Information Codes O 25

240 QTY Quantity O 10

241 HCP Health Care Pricing O 1


October 31, 2007 23

LOOP ID – 2305 6

242 CR7 Home Health Treatment Plan Certification O 1

243 HSD Health Care Services Delivery O 12

LOOP ID 2310 9








LOOP ID – 2320 10

290 SBR Subscriber Information O 1

295 CAS Claim Adjustment O 99


305 DMG Demographic Information O 1

310 OI Other Health Insurance Information O 1

315 MIA Medicare In-Patient Adjudication O 1

320 MOA Medicare Out-Patient Adjudication O 1

LOOP ID 2330 10








LOOP ID –2400 >1

365 LX Assigned Number O 1

370 SV1 Professional Service O 1

375 SV2 Institutional Service O 1

380 SV3 Dental Service O 1

382 TOO Tooth Identification O 32

385 SV4 Drug Service O 1

400 SV5 Durable Medical Equipment Service O 1

405 SV6 Anesthesia Service O 1

410 SV7 Drug Adjudication O 1

415 HI Health Care Information Codes O 25

420 PWK Paper work O 10

425 CR1 Ambulance Certification O 1

430 CR2 Chiropractic Certification O 5

435 CR3 Durable Medical Equipment Certification O 1

440 CR4 Enteral or Parenteral Therapy Certification O 3

445 CR5 Oxygen Therapy Certification O 1

450 CRC Conditions Indicator O 3


460 QTY Quantity O 5

462 MEA Measurements O 20

465 CN1 Contract Information O 1



480 K3 File Information O 10

485 NTE Note/Special Instruction O 10

488 PS1 Purchase Service O 1

490 IMM Immunization Status Code O >1

491 HSD Health Care Services Delivery O 1

492 HCP Health Care Pricing O 1


October 31, 2007 24

LOOP ID –2410 >1

494 LIN Item Identification O 1

495 CTP Pricing Information O 1


LOOP ID –2420 10

500 NM1 Individual or Organizational name O 1




520 N4 Geographic Location O 1

525 REF Reference: Identification O 20


LOOP ID –2430 >1

540 SVD Service Line Adjudication Information O 1

545 CAS Claims Adjustment O 99


LOOP ID – 2440 >1

551 LQ Industry Code O 1

552 FRM Supporting Documentation M 99

555 SE Transaction Set Trailer M 1


October 31, 2007 25

IMPLEMENTATION

ST TRANSACTION SET HEADER

Loop: N/A Usage: REQUIRED Repeat: 1 Example: ST*837*0001~

STANDARD

ST Transaction Set Header

Level: Header Position: 005 Loop:

Requirement: Mandatory Max Use: 1 Purpose: To indicate the start of a transaction set and to assign a control number. Semantic: 01 The transaction set identifier (ST01) used by the translation routines of the interchange

partners to select the appropriate transaction set definition (e.g., 810 selects the invoice transaction set).

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

ST01 143 Transaction Set Identifier Code R 3/3 M/Z ID 3/3

ST02 329 Transaction Set Control Number R 4/9 M AN 4/9

ELEMENT SUMMARY

ST01 Transaction Set Identifier Code

Code uniquely identifying a Transaction Set

CODE DEFINITION 837 Health Care Claim

ST02 Transaction Set Control Number

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

Unique Number to identify transaction set


October 31, 2007 26

IMPLEMENTATION

BHT BEGINNING OF HIERARCHICAL TRANSACTION

Loop: N/A Usage: REQUIRED Repeat: 1 Example: BHT*0019*00*0123*20020318*0932*CH~

STANDARD

BHT Beginning of Hierarchical Transaction

Level: Header Position: 010 Loop:

Requirement: Mandatory Max Use: 1 Purpose: To define the business hierarchical structure of the transaction set and to identify the business

application purpose and reference data, i.e., number, date, and time. Semantic: 03 BHT03 is the number assigned by the originator to identify the transaction within the

originator’s business application system. 04 BHT04 is the data the transaction was created within the business application system. 05 BHT05 is the time the transaction was created within the business application system.

DIAGRAM

SEQ. NO.

REF. NO.

ASC X12 NAME

SF

REQ.

ASC X12 ATTRIBUTES

BHT01 1005 Hierarchical Structure Code R 4/4 M ID 4/4

BHT02 353 Transaction Set Purpose Code R 2/2 M ID 2/2

BHT03 127 Reference Identification S 1/30 O/Z AN 1/30

BHT04 373 Date S 8/8 O/Z DT 8/8

BHT05 337 Time S 4/8 O/Z TM 4/8

BHT06 640 Transaction Type Code S 2/2 O ID 2/2


October 31, 2007 27

ELEMENT SUMMARY

BHT01 Hierarchical Structure Code

Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set

CODE DEFINITION 0019 Information Source, Subscriber, and Dependent.

BHT02 Transaction Set Purpose Code

Code identifying purpose of transaction set

CODE DEFINITION 00 Original 18 Reissue

BHT03 Reference Identification


Reference Identification for Beginning of Hierarchical Transaction

BHT04 Date Date expressed as CCYYMMDD

Date For Beginning of Hierarchical Transaction

BHT05 Time

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

Time for Beginning of Hierarchical Transaction

BHT06 Transaction Type Code

Code specifying the type of transaction

CODE DEFINITION CH Chargeable


October 31, 2007 28

IMPLEMENTATION

NM1 SUBMITTER NAME

Loop: 1000A Repeat: 1 Usage: REQUIRED Repeat: 1 Notes: Refer to front matter section 1.6.1 Example: NM1*41*2*DCV*****46*ETI-NUMBER-123456789~

STANDARD

NM1 Individual or Organizational Name

Level: Header Position: 020 Loop: 1000 Repeat: 10

Requirement: Optional Max Use: 1 Purpose: To specify identifying information.

Syntax: 08 P0809 – If either NM108 or NM109 is present, then the other is required. 11 C1110 – If NM111 is present, then NM110 is required Semantic: 02 NM102 qualifies NM103

Comments: 10 NM110 and NM111 further define the type of entity in NM101.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

NM101 98 Entity Identifier Code R 2/3 M ID 2/3

NM102 1065 Entity Type Qualifier R 1/1 M/Z ID 1/1

NM103 1035 Name Last or Organization Name R 1/35 O AN 1/35

NM104 1036 Name First NU O AN 1/25

NM105 1037 Name Middle NU O AN 1/25

NM106 1038 Name Prefix NU O AN 1/10

NM107 1039 Name Suffix NU O AN 1/10

NM108 66 Identification Code Qualifier R 1/2 X ID 1/2

NM109 67 Identification Code R 2/80 X AN 2/80

NM110 706 Entity Relationship Code NU X ID 2/2

NM111 98 Entity Identifier Code NU O ID 2/3


October 31, 2007 29

ELEMENT SUMMARY

NM101 Entity Identifier Code

Code identifying an organizational entity, a physical location, property or an individual

CODE DEFINITION 41 Submitter

NM102 Entity Type Qualifier

Code qualifying the type of entity

CODE DEFINITION 2 Non-Person Entity

NM103 Submitter Name

Individual last name or organizational name

Submitter Name

NM104 Name First Individual first name

Not Used

NM105 Name Middle

Individual middle name or initial

Not Used

NM106 Name Prefix Prefix to individual name

Not Used

NM107 Name Suffix

Suffix to individual name

Not Used

NM108 Identification Code Qualifier Code designating the system/method of code structure used for Identification Code (67)

CODE DEFINITION 46 Electronic Transfer Identification Number (ETIN)

NM109 Identification Code

Code identifying a party or other code

Submitter Identification Code Refer to the front matter section 1.6.1

NM110 Entity Relationship Code

Code describing entity relationship

Not Used

NM111 Entity Identifier Code Code identifying an organizational entity, a physical location, property or an individual

Not Used


October 31, 2007 30

IMPLEMENTATION

NM1 RECEIVER NAME

Loop: 1000B Repeat: 1 Usage: REQUIRED Repeat: 1 Example: NM1*40*2*STATEFARM INSURANCE~

STANDARD


Level: Header Position: 020 Loop: 1000 Repeat: 10




DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes








NM108 66 Identification Code Qualifier S 1/2 X ID 1/2

NM109 67 Identification Code S 2/80 X AN 2/80




October 31, 2007 31

ELEMENT SUMMARY



CODE DEFINITION 40 Receiver



CODE DEFINITION 2 Non-Person Entity

NM103 Receiver Name


Receiver’s Name


Not Used

NM105 Name Middle


Not Used


Not Used

NM107 Name Suffix


Not Used


CODE DEFINITION 46 Electronic Transfer Identification Number (ETIN)

This element will not be used by Data Conversion Vendor



Submitter Identification Code This element will not be used by Data Conversion Vendor



Not Used


Not Used


October 31, 2007 32

IMPLEMENTATION

HL BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL

Loop: 2000A - Billing/Pay-To Provider Hierarchical Level Repeat: >1 Usage: REQUIRED Repeat: 1 Example: HL*1**20*1~

STANDARD

HL Hierarchical Level

Level: Detail Position: 001 Loop: 2000 Repeat: >1

Requirement: Mandatory Max Use: 1 Purpose: To identify dependencies among and the content of hierarchically related groups of data

segments Comments: 00 The HL segment is used to identify levels of detail information using a

hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.

00 The HL segment defines a top-down/left-right ordered structure. 01 HL01 shall contain a unique alphanumeric number for each occurrence of

the Hl segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of Hl01 would be “1” for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.

02 HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

03 HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item- level information.

04 HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

HL01 628 Hierarchical ID Number R 1/12 M AN 1/12

HL02 734 Hierarchical Parent ID Number NU O AN 1/12

HL03 735 Hierarchical Level Code R 1/ 2 M ID 1/2

HL04 736 Hierarchical Child Code R 1/1 O ID 1/1


October 31, 2007 33

ELEMENT SUMMARY

HL01 Hierarchical ID Number A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

HL01 is used to indicate the number of occurrences of HL segment

HL02 Hierarchical Parent ID Number

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

Not Used

HL03 Hierarchical Level Code Code defining the characteristic of a level in a hierarchical structure

CODE DEFINITION 20 Information Source

HL04 Hierarchical Child Code

Code indicating if there are hierarchical child data segments subordinate to the level being described

CODE DEFINITION 1 Additional Subordinate HL Data Segment in this Hierarchical Structure.


October 31, 2007 34

IMPLEMENTATION

NM1 BILLING PROVIDER NAME

Loop: 2010AA - Billing Provider Name Repeat: 1 Usage: REQUIRED Repeat: 1 Example: NM1*85*2*JONES HOSPITAL~ NM1*85*2*UNKNOWN ~ NM1*85*2*JONES HOSPITAL*****XX*456093125~

Notes:

STANDARD


Level: Detail Position: 015 Loop: 2010 Repeat: 10


Syntax: 08 P0809 – If either NM108 or NM109 is present, then the other is required. 11 C1110 – If NM111 is present, then NM110 is required

Semantic: 02 NM102 qualifies NM103 Comments: 10 NM110 and NM111 further define the type of entity in NM101.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes




NM104 1036 Name First S 1/25 O AN 1/25




NM108 66 Identification Code Qualifier S 1/ 2 X ID 1/2





October 31, 2007 35

ELEMENT SUMMARY



CODE DEFINITION 85 Billing Provider (Refers to Billing Provider/Submitter, and encounter

reporting entity)

NM102 Entity Type Qualifier Code qualifying the type of entity

CODE DEFINITION 1 Person 2 Non-Person Entity

Defaults to Value “2” if unavailable or unreadable

NM103 Billing provider Name or Last Name


For all bill types (except Medicaid UB92) Paper Form Equivalent: UB BOX #1 For Medicaid UB92 Paper Form Equivalent: UB92 BOX #84

For Medicare, Non Medicare, and Medicare Summary Notice (MSN) Critical default value is “UNKNOWN”. When critical default value is used, 2300 NTE01 is set to “CD Bill Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID

For Medicaid and MSN dup value defaults to “UNKNOWN”

NM104 Name First

Individual first name

Billing Provider First Name Required if NM102=1 (Person)

Defaults to “UNKNOWN” If NM102=1 and NM104 is unavailable or unreadable

NM105 Name Middle


Not Used


Not Used

NM107 Name Suffix


Not Used


October 31, 2007 36


CODE DEFINITION 24 Employer’s Identification Number 34 Social Security Number XX Health Care Financing Administration National Provider Identifier

Required when the National provider ID is available. Otherwise one of the other listed codes may be used.

Set Value to " XX” if- National Provider ID (NPI) is available and legible. If “XX - NPI” is used, then either the Employer’s Identification Number or the Social Security Number of the provider must be carried in the REF in this loop.

Defaults to 24



If NM108 = XX, Paper Form Equivalent is UB04 Box 56 If NM108 = 24 or 34, for all bill types except Medicaid Paper Form Equivalent: UB92 BOX #5 For Medicaid Paper Form Equivalent: UB92 BOX #84

If NM108 = XX, for Non Medicare, and Medicare default to “UNKNOWN”. IF NM108 = 24 or 34, for Non-Medicare and Medicare, critical default value is “UNKNOWN”. When critical default value is used, 2300 NTE01 is set to “CD Bill Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID.


For MSN lookup on Provider file if none then defaults to “UNKNOWN”



Not Used


Not Used


October 31, 2007 37

IMPLEMENTATION

N3 BILLING PROVIDER ADDRESS

Loop: 2010AA - Billing Provider Name Usage: REQUIRED Repeat: 1 Example: N3*225 MAIN STREET BARKLEY BUILDING~ N3*UNKNOWN~

STANDARD

N3 Address Information

Level: Detail Position: 025 Loop: 2010

Requirement: Optional Max Use: 2 Purpose: To specify the location of the named party

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

N301 166 Address Information R 1/30 M AN 1/55

N302 166 Address information S 1/30 O AN 1/55

ELEMENT SUMMARY


Address information


For Medicare, Non Medicare, and Medicare Summary Notice (MSN) Critical default value is “UNKNOWN”. When critical default value is used, 2300 NTE01 is set to “CD Bill Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID


When the Critical Value or the address is longer than 30 Characters: Split the information meaningfully and key into N301 and N302 (Maximum of 30 characters in each element)


Address information

Required if address line is greater than 30 characters


October 31, 2007 38

IMPLEMENTATION

N4 BILLING PROVIDER CITY/STATE/ZIP CODE

Loop: 2010AA - Billing Provider Name Usage: REQUIRED Repeat: 1 Example: N4*BLOOMINGTON*IL*671045641~ N4*UNKNOWN*ZZ*999~

STANDARD

N4 Geographic Location


Requirement: Optional Max Use: 1 Purpose: To specify the geographic place of the named party

Syntax: 06 C0605 – If N406 is present, then N405 is required. Comments: 01 A combination of either N401 through N404, or N405 and N406 may be

adequate to specify a location. 02 N402 is required only if city name (N401) is in the U.S. or Canada.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

N401 19 City Name R 2/30 O AN 2/30

N402 156 State or Province Code R 2/2 O ID 2/2

N403 116 Postal Code R 3/15 O ID 3/15

N404 26 Country Code NU O ID 2/3

N405 309 Location Qualifier NU X ID 1/2

N406 310 Location Identifier NU O AN 1/30


October 31, 2007 39

ELEMENT SUMMARY

N401 Billing Provider City Name

Free-form text for city name

For all bill types (except Medicaid UB92) Paper Form Equivalent: UB BOX #1 For Medicaid UB92 Paper Form Equivalent: UB92 BOX # 84

For Non Medicare, Medicare, and Medicare Summary Notice (MSN) Critical default value is “UNKNOWN”. When critical default value is used, 2300 NTE01 is set to “CD Bill Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID.


N402 State or Province Code

Code (Standard State/Province) as defined by appropriate government agency


For Non Medicare, Medicare, and Medicare Summary Notice (MSN) Critical default value is “ZZ”. When critical default value is used, 2300 NTE01 is set to “CD Bill Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID.

For Medicaid and MSN dup value defaults to “ZZ”

N403 Postal Code

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)


For Non Medicare, Medicare, and Medicare Summary Notice (MSN) Critical default value is “999”. When critical default value is used, 2300 NTE01 is set to “CD Bill Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID.

For Medicaid and MSN dup value defaults to “999”

N404 Country Code

Code identifying the country

Not Used

N405 Location Qualifier Code identifying type of location

Not Used

N406 Location Identifier

Code which identifies a specific location

Not Used


October 31, 2007 40

IMPLEMENTATION

REF BILLING PROVIDER SECONDARY IDENTIFICATION

Loop: 2010AA - Billing Provider Name Usage: SITUATIONAL Repeat: 2 Example: REF*EI*984763221~ REF*EI*UNKNOWN~

STANDARD

REF Reference Identification


Requirement: Optional Max Use: 20 Purpose: To specify identifying information. Syntax: 02 R0203 – At least one REF02 or REF03 is required.

03 P0304 - If either C04003 or C04004 is present, then the other is required. 05 P0506 – If either C04005 or C04006 is present, then the other is required.

Semantic: 04 REF04 contains data relating to the value cited in REF02.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

REF01 128 Reference Identification Qualifier R 2/3 M ID 2/3

REF02 127 Reference Identification R 1/30 X AN 1/30

REF03 352 Description NU X AN 1/80

REF04 C040 Reference Identifier NU O/Z

REF04-01 128 Reference Identification Qualifier NU M ID 2/3

REF04-02 127 Reference Identification NU M AN 1/30

REF04-03 128 Reference Identification Qualifier NU X ID 2/3

REF04-04 127 Reference Identification NU X AN 1/30




October 31, 2007 41

ELEMENT SUMMARY

REF01 Reference Identification Qualifier

Code qualifying the Reference Identification

CODE DEFINITION EI Employer’s Identification Number SY Social Security Number The social security number may not be used for Medicare.

Required when the National provider ID in 2010AA NM109



For all bill types (except Medicaid UB92) Paper Form Equivalent: UB BOX #5 For Medicaid Paper Form Equivalent: UB92 BOX #84 Critical default value is “UNKNOWN”. When critical default value is used, 2300 NTE01 is set to “CD Bill Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID. Required when the National provider ID is in 2010AA NM109

REF03 Description

A free-form description to clarify the related data elements and their content

Not Used

REF04 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

Not Used

REF04-01Reference Identification Qualifier


Not Used

REF04-02Reference Identification Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Not Used



Not Used


Not Used



Not Used


Not Used


October 31, 2007 42

IMPLEMENTATION

PER BILLING PROVIDER CONTACT INFORMATION

Loop: 2010AA - Billing Provider Name Usage: SITUATIONAL Repeat: 1 Situational Rule: Required for Non-Medicare bills if present and legible in box #1 of the UB. Example: PER*IC**TE*3134554321~

STANDARD

PER Administrative Communications Contact

Level: Header Position: 045 Loop: 2010AA

Requirement: Optional Max Use: 2 Purpose: To identify a person or office to whom administrative communications should be directed

Syntax: 03 P0304 – If either PER03 or PER04 is present, then the other is required. 05 P0506 – If either PER05 or PER06 is present, then the other is required 06 P0708 – If either PER07 or PER08 is present, then the other is required

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

PER01 366 Contact Function Code R 2/2 M ID 2/2

PER02 93 Name NU O AN 1/60

PER03 365 Communication Number Qualifier R 2/2 X ID 2/2

PER04 364 Communication Number R 1/80 X AN 1/80

PER05 365 Communication Number Qualifier NU X ID 2/2

PER06 364 Communication Number NU X AN 1/80

PER07 365 Communication Number Qualifier NU X ID 2/2

PER08 364 Communication Number NU X AN 1/80

PER09 443 Contact Inquiry Reference NU O AN 1/20


October 31, 2007 43

ELEMENT SUMMARY

PER01 Contact Function Code

Code identifying the major duty or responsibility of the person or group named

CODE DEFINITION IC Information Contact

PER02 Name

Free-form name

Not Used

PER03 Communication Number Qualifier Code identifying the type of communication number

CODE DEFINITION TE Telephone

PER04 Communication Number

Complete communications number including country or area code when applicable

Telephone Number


Not Used



Not Used


Not Used



Not Used

PER09 Contact Inquiry Reference Additional reference number or description to clarify a contact number

Not Used


October 31, 2007 44

IMPLEMENTATION

NM1 PAY TO PROVIDER NAME

Loop: 2010AB – Pay To Provider Name Repeat: 1 Usage: SITUATIONAL Repeat: 1 Situational Rule: Required for Medicaid bills Example: NM1*87*2*ELLIS HOSPITAL*****24*123456789~

NM1*87*2*UNKNOWN ~ NM1*87*2*JONES HOSPITAL*****XX*456093125~

STANDARD






DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes








NM108 66 Identification Code Qualifier S 1/ 2 X ID 1/2





October 31, 2007 45

ELEMENT SUMMARY



CODE DEFINITION 87 Pay to Provider (Refers to Pay To Provider/Submitter, and encounter

reporting entity)

NM102 Entity Type Qualifier Code qualifying the type of entity

CODE DEFINITION 1 Person 2 Non-Person Entity

NM103 Pay to provider Name or Last Name


For Medicaid Paper Form Equivalent: UB92 BOX #1 For UB04 Non-Medicare, UB04 Medicaid and UB04 Medicare, Paper Form Equivalent: UB04 BOX #2

If value is present but unreadable, critical default value is “UNKNOWN”. When critical default value is used, 2300 NTE01 is set to “CD Pay To Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID If value present in UB04 BOX #2 is State Farm, leave blank.

NM104 Name First


Pay To Provider First Name Required if NM102=1 (Person) Critical default value is “UNKNOWN”. When critical default value is used, 2300 NTE01 is set to “CD Pay To Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID

NM105 Name Middle


Not Used


Not Used

NM107 Name Suffix


Not Used


CODE DEFINITION 24 Employers Identification Number XX National Provider Identifier.


October 31, 2007 46

Set Value to “XX” if NM109 = 10 digits. Set value to “24” for all other values. If XX- NPI is used, then the Employer Identification Number of the provider must be carried in the REF in this loop.



For Medicaid Paper Form Equivalent: UB92 BOX#5; UB04 BOX #2 For Medicare and Non-Medicare Paper Form Equivalent: UB04 Box #2

If NM108 = 24, critical default value is “UNKNOWN”. When critical default value is used, 2300 NTE01 is set to “CD Pay To Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID. If NM109 = XX, default to “UNKNOWN” If value other than State Farm is present in box 2 and no tax ID is present, default to bill provider tax ID (only when pay to provider loop is sent).

NM110 Entity Relationship Code Code describing entity relationship

Not Used



Not Used


October 31, 2007 47

IMPLEMENTATION

N3 PAY TO PROVIDER ADDRESS

Loop: 2010AB – Pay To Provider Name Usage: SITUATIONAL Repeat: 1 Situational Rule: Required for Medicaid bills Example: N3*225 MAIN STREET BARKLEY BUILDING~ N3*UNKNOWN~

STANDARD




DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes



ELEMENT SUMMARY

N301 Address Information Address information


If value is present but unreadable, critical default value is “UNKNOWN”. When critical default value is used, 2300 NTE01 is set to “CD Pay To Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID

N302 Address Information Address information

Required, if address line is greater than 55 characters.


October 31, 2007 48

IMPLEMENTATION

N4 PAY TO PROVIDER CITY/STATE/ZIP CODE

Loop: 2010AB – Pay To Provider Name Usage: SITUATIONAL Repeat: 1 Situational Rule: Required for Medicaid bills Example: N4*BLOOMINGTON*IL*671045641~ N4*UNKNOWN*ZZ*999~

STANDARD






DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

N401 19 City Name R 2/30 O AN 2/30







October 31, 2007 49

ELEMENT SUMMARY

N401 Billing Provider City Name



If value is present but unreadable, critical default value is “UNKNOWN”. When critical default value is used, 2300 NTE01 is set to “CD Pay To Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID

N402 State or Province Code



If value is present but unreadable, critical default value is “ZZ”. When critical default value is used, 2300 NTE01 is set to “CD Pay To Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID

N403 Postal Code



If value is present but unreadable, critical default value is “999”. When critical default value is used, 2300 NTE01 is set to “CD Pay To Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID

N404 Country Code


Not Used


Not Used


Code which identifies a specific location

Not Used


October 31, 2007 50

IMPLEMENTATION

REF PAY TO PROVIDER SECONDARY IDENTIFICATION

Loop: 2010AB – Pay To Provider Name Usage: SITUATIONAL Repeat: 2 Situational Rule: Required for Medicaid bills Example: REF*EI*984763221~ REF*EI*UNKNOWN~

STANDARD






DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes












October 31, 2007 51

ELEMENT SUMMARY



CODE DEFINITION EI Employer’s Identification Number Required when 2010AB NM108 = XX



For all bill types Paper Form Equivalent: UB BOX# 5

Critical default value is “UNKNOWN”. When critical default value is used, 2300 NTE01 is set to “CD Pay To Prov”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID Required when the National Provider ID is in 2010AB NM109

REF03 Description


Not Used


Not Used



Not Used


Not Used



Not Used


Not Used



Not Used


Not Used


October 31, 2007 52

IMPLEMENTATION

HL SUBSCRIBER HIERARCHICAL LEVEL

Loop: 2000B - Subscriber Hierarchical Level Repeat: >1 Usage: REQUIRED Repeat: 1 Example: HL*251*250*22*1~

STANDARD












October 31, 2007 53

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

HL01 628 Hierarchical ID Number R 1/12 M AN 1/12

HL02 734 Hierarchical Parent ID Number R 1/12 O AN 1/12

HL03 735 Hierarchical Level Code R 1/ 2 M ID 1/2

HL04 736 Hierarchical Child Code R 1/1 O ID 1/1

ELEMENT SUMMARY


HL01 identifies the number of occurrences of Subscriber Hierarchical Level



HL02 ID Number tells the relation ship between the Subscriber Hierarchical Levels


CODE DEFINITION 22 Information Source



CODE DEFINITION 0 No Subordinate HL Segment in this Hierarchical Structure 1 Additional Subordinate HL Data Segment in this Hierarchical Structure.


October 31, 2007 54

IMPLEMENTATION

SBR SUBSCRIBER INFORMATION

Loop: 2000B - Subscriber Hierarchical Level Usage: REQUIRED Repeat: 1 Situational Rule: Required if necessary to meet specific Trading Partner data requirements. Notes: Example: SBR*P~

STANDARD

SBR Subscriber Information


Requirement: Optional Max Use: 1 Purpose: To record information specific to the primary insured and the insurance carrier that insured Semantic: 02 SBR02 specifies the relationship to the person insured..

03 SBR03 is policy or group number. 04 SBR04 is plan name. 07 SBR07 is destination payer code. A “Y” value indicates the payer is the destination

payer, an “N” value indicates the payer is not the destination payer.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

SBR01 1138 Payer Responsibility Sequence Number Code

R 1/1 M ID 1/1

SBR02 1069 Individual Relationship Code NU O/Z ID 2/2

SBR03 127 Reference Identification NU O/Z AN 1/30

SBR04 93 Name NU O/Z AN 1/60

SBR05 1336 Insurance Type Code NU O ID 1/3

SBR06 1143 Coordination of Benefits Code NU O ID 1/1

SBR07 1073 Yes/No Condition or Response Code NU O/Z ID 1/1

SBR08 584 Employment Status Code NU O ID 2/2

SBR09 1032 Claim Filing Indicator Code NU O ID 1/2


October 31, 2007 55

ELEMENT SUMMARY

SBR01 Payer Responsibility Sequence Number Code Code identifying the insurance carrier’s level of responsibility for a payment of a claim CODE DEFINITION P Primary

SBR02 Individual Relationship Code

Code indicating the relationship between two individuals or entities

Not Used

SBR03 Reference Identification Reference information as defined for a particular Transaction set or as specified by the Reference identification Qualifier

Not Used

SBR04 Name Free-form name

Not Used

SBR05 Insurance Type Code Code identifying the type of insurance policy within a specific insurance program

Not Used

SBR06 Coordination of Benefits Code Code identifying whether there is a coordination of benefits

Not Used

SBR07 Yes/No Condition or Response Code Code indicating a Yes or No condition or response

Not Used

SBR08 Employment Status Code Code showing the general employment status of an employee/claimant

Not Used

SBR09 Claim Filing Indicator Code Code identifying type of claim

Not Used


October 31, 2007 56

IMPLEMENTATION

NM1 SUBSCRIBER NAME

Loop: 2010BA – Subscriber Name Usage: REQUIRED Repeat: 1 Example: NM1*IL*1*DOE*JOHN*T***MI*739004273~

STANDARD



Requirement: Optional Max Use: 1 Purpose: To specify identifying information. Set Notes:



DIAGRAM

Seq. No. Ref.

No. ASC X12 Name SF

Req. ASC X12 Attributes





NM105 1037 Name Middle S 1/25 O AN 1/25



NM108 66 Identification Code Qualifier R 1/ 2 X ID 1/2

NM109 67 Identification Code R 2/80 X AN 2/80




October 31, 2007 57

ELEMENT SUMMARY



CODE DEFINITION IL Insured or Subscriber



CODE DEFINITION 1 Person

NM103 Name Last or Organization Name


Replicate from loop 2010CA – Patient name Element NM103


If NM104 in loop 2010CA is Present then Replicate from loop 2010CA – Patient name Element NM104

NM105 Name Middle Individual middle name or initial

If NM105 in loop 2010CA is Present then Replicate from loop 2010CA – Patient name Element NM105

NM106 Name Prefix

Prefix to individual name

Not Used

NM107 Name Suffix Suffix to individual name

Not Used

NM108 Identification Code Qualifier

Code designating the system/method of code structure used for Identification Code (67)

CODE DEFINITION MI Member Identification Number



This element is derived from the eligibility check process


Not Used



Not Used


October 31, 2007 58

IMPLEMENTATION

REF SUBSCRIBER SECONDARY IDENTIFICATION

Loop: 2010BA - Subscriber Name Usage: SITUATIONAL Repeat: 1 Situational Rule: Required if necessary to meet specific Trading Partner data requirements. Notes: Example: REF*23*033978941~

STANDARD






DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes






October 31, 2007 59

ELEMENT SUMMARY



CODE DEFINITION 23 Client Number



Reporting Number


Not Used


To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

Not Used


October 31, 2007 60

IMPLEMENTATION

HL PATIENT HIERARCHICAL LEVEL

Loop: 2000C - Patient Hierarchical Level Repeat: >1 Usage: REQUIRED Repeat: 1 Example: HL*251*250*23*0~

STANDARD











DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

HL01 628 Hierarchical ID Number R 1/ 12 M AN 1/12

HL02 734 Hierarchical Parent ID Number R 1 /12 O AN 1/12

HL03 735 Hierarchical Level Code R 1 / 2 M ID 1/2

HL04 736 Hierarchical Child Code R 1 /1 O ID 1/1


October 31, 2007 61

ELEMENT SUMMARY


HL01 identifies the number of occurrences of Patient Hierarchical Level



HL02 ID Number tells the relation ship between the Patient Hierarchical Levels


CODE DEFINITION 23 Dependent



CODE DEFINITION 0 No Subordinate HL Segment in this Hierarchical Structure


October 31, 2007 62

IMPLEMENTATION

PAT PATIENT INFORMATION

Loop: 2000C - Patient Hierarchical Level Usage: SITUATIONAL Repeat: 1 Situational Rule: Required if necessary to meet specific Trading Partner data requirements. Notes: Example: PAT*21~

STANDARD

PAT Patient Information


Requirement: Optional Max Use: 1 Purpose: To supply patient information Syntax: 05 P0506 – If either PAT05 or PAT06 is present, then the other is required.

07 P0708 – If either PAT07 or PAT08 is present, then the other is required. Semantic: 06 PAT06 is the date of death

08 PAT08 is the patient’s weight. 09 PAT09 indicates whether the patient is pregnant or not pregnant. Code “Y” indicates

the patient is pregnant; code “N” indicates the patient is not pregnant.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

PAT01 1069 Individual Relationship Code R 2/2 O ID 2/2

PAT02 1384 Patient Location Code NU O ID 1/1

PAT03 584 Employment Status Code NU O ID 2/2

PAT04 1220 Student Status Code NU O ID 1/1

PAT05 1250 Date Time Period Format Qualifier NU X ID 2/3

PAT06 1251 Date Time Period NU X/Z AN 1/35

PAT07 355 Unit or Basis for Measurement Code NU X ID 2/2

PAT08 81 Weight NU X/Z R 1/10

PAT09 1073 Yes/No Condition or Response Code NU O/Z ID 1/1


October 31, 2007 63

ELEMENT SUMMARY

PAT01 Individual Relationship Code Code indicating the relationship between two individuals or entities

CODE DEFINITION 21 Unknown

PAT02 Patient Location Code

Code identifying the location where patient is receiving medical treatment

Not Used

PAT03 Employment Status Code Code showing the general employment status of an employee/claimant

Not Used

PAT04 Student Status Code

Code indicating the student status of the patient if 19 years of age or older, not handicapped and not the insured Not Used

PAT05 Date Time Period Format Qualifier Code indicating the date format, time format, or date and time format

Not Used

PAT06 Date Time Period Expression of a date, a time, or range of dates, times or dates and times

Not Used

PAT07 Unit or Basis for Measurement Code Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

Not Used

PAT08 Weight Numeric value of weight

Not Used

PAT09 Yes/No Condition or Response Code Code indicating a Yes or No condition or response

Not Used


October 31, 2007 64

IMPLEMENTATION

NM1 PATIENT NAME

Loop: 2010CA - Patient Name Repeat: 1 Usage: REQUIRED Repeat: 1 Example: NM1*QC*1*DOE*SALLY*R~

STANDARD



Requirement: Optional Max Use: 1 Purpose: To specify identifying information. Set Notes:

Syntax: 08 P0809 – If either NM108 or NM109 is present, then the other is required. 11 C1110 – If NM111 is present then NM110 is required


DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes




NM104 1036 Name First R 1/25 O AN 1/25

NM105 1037 Name Middle S 1/25 O AN 1/25



NM108 66 Identification Code Qualifier NU X ID 1/2

NM109 67 Identification Code NU X AN 2/80




October 31, 2007 65

ELEMENT SUMMARY



CODE DEFINITION QC Patient



CODE DEFINITION 1 Person






NM105 Name Middle




Not Used

NM107 Name Suffix


Not Used


Not Used



Not Used


Not Used



Not Used


October 31, 2007 66

IMPLEMENTATION

N3 PATIENT ADDRESS

Loop: 2010CA - Patient Name Usage: REQUIRED Repeat: 1 Example: N3*13 Lake Cook Rd~

STANDARD




DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes



ELEMENT SUMMARY


Address information



Address information

Required if address line is greater than 55 characters


October 31, 2007 67

IMPLEMENTATION

N4 PATIENT CITY/STATE/ZIP CODE

Loop: 2010CA Usage: REQUIRED Repeat: 1 Example: N4*CENTERVILLE*PA*17111~

STANDARD






DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

N401 19 City Name R 2/30 O AN 2/30







October 31, 2007 68

ELEMENT SUMMARY

N401 Patient City Name


This element is derived from the eligibility check process N402 State or Province Code


This element is derived from the eligibility check process N403 Postal Code


This element is derived from the eligibility check process N404 Country Code


Not Used


Not Used


Code which identifies a specific location.

Not Used


October 31, 2007 69

IMPLEMENTATION

DMG PATIENT DEMOGRAPHIC INFORMATION (DMG)

Loop: 2010CA - Patient Name Usage: REQUIRED Repeat: 1 Example: DMG*D8*19290730*M~

STANDARD

DMG Demographic Information


Requirement: Optional Max Use: 1 Purpose: To supply demographic information Set Notes: Syntax: 01P0102 - If either DMG01 or DMG02 is present, then the other is required. Semantic: 02 DMG02 is the date of birth.

07 DMG07 is the country of citizenship. 09 DMG09 is the age in years.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

DMG01 1250 Date Time Period Format Qualifier R 2/3 X ID 2/3

DMG02 1251 Date Time Period R 1/35 X/Z AN 1/35

DMG03 1068 Gender Code S 1/1 O ID 1/1

DMG04 1067 Marital Status Code NU O ID 1/1

DMG05 1109 Race or Ethnicity Code NU O ID 1/1

DMG06 1066 Citizenship Status Code NU O ID 1/2

DMG07 26 Country Code NU O/Z ID 2/3

DMG08 659 Basis of Verification Code NU O ID 1/2

DMG09 380 Quantity NU O/Z R 1/15


October 31, 2007 70

ELEMENT SUMMARY

DMG01 Date Time Period Format Qualifier

Code indicating the date format, time format, or date and time format

CODE DEFINITION D8 Date Expressed in the format CCYYMMDD

DMG02 Patient Birth Date Time Period

Expression of a date, a time, or range of dates, times or dates and times


DMG03 Gender Code Code indicating the sex of the individual

This element is derived from the eligibility check process if value = F or M If no value is derived then defaults to value “U”

CODE DEFINITION F Female M Male U Unknown

DMG04 Marital Status code Code defining the marital status of a person

Not Used

DMG05 Race or Ethnicity Code

Code indicating the racial or ethnic background of a person; it is normally self reported; under certain circumstances this information is collected for United States Government statistical purpose

Not Used

DMG06 Citizenship Status Code

Code indicating citizenship status

Not Used

DMG07 Country Code


Not Used

DMG08 Basis of Verification Code Code indicating the basis of verification

Not Used

DMG09 Quantity

Numeric value of quantity

Not Used


October 31, 2007 71

IMPLEMENTATION

CLM CLAIM INFORMATION

Loop: 2300 - Claim Information Repeat: 100 Usage: REQUIRED Repeat: 1 Notes: Refer to front matter section 1.6.9 Example: CLM*01319300001*500.32***11:A:1***Y***AA:EM:OA~ CLM*UNKNOWN*500.32***11:A:1***Y***AA:EM:OA~

STANDARD

CLM Health Claim


Requirement: Optional Max Use: 1 Purpose: To specify basic data about the claim Semantic: 02 CLM02 is the total amount of all submitted charges of service segments for this claim.

06 CLM06 is provider signature on file indicator. A “Y” value indicates the provider signature is on file; an “N” value indicates the provider signature is not on file.

08 CLM08 is assignment of benefits indicator. A “Y” value indicates insured or authorized person authorizes benefits to be assigned to the provider, an “N” value indicates benefits have not been assigned to the provider.

13 CLM 13 is CHAMPUS non-availability indicator. A “Y” value indicates a statement of non-availability is on file; and “N” value indicates statement of non-availability is not on file or not necessary.

15 CLM15 is charges itemized by service indicator. A “Y” value indicates charges are summarized by service.

18 CLM18 is explanation of benefit (EOB) indicator. A “Y” value indicates that a paper EOB is requested; an “N” value indicates that no paper EOB is requested.

02 C023-02 qualifies C023-01 and C023-03. Comments: 04 C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02,

or C024-03 is equal to “AA”.


October 31, 2007 72

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

CLM01 1028 Claim submitter’s Identifier R 1/38 M AN 1/38

CLM02 782 Monetary amount R 1/18 O/Z R 1/18

CLM03 1032 Claim Filing Indicator Code NU O ID 1/2

CLM04 1343 Non Institutional claim Type Code NU O ID 1/2

CLM05 C023 Health Care Service Location Information R O

CLM05-01 1331 Facility Code Value R 1/ 2 M AN 1/2

CLM05-02 1332 Facility Code Qualifier R 1/ 2 O/Z ID 1/2

CLM05-03 1325 Claim Frequency Type Code R 1/1 O ID 1/1

CLM06 1073 Yes/No Condition or Response Code NU O/Z ID 1/1

CLM07 1359 Provider Accept Assignment Code NU O ID 1/1

CLM08 1073 Yes/No Condition or Response Code R 1/1 O/Z ID 1/1

CLM09 1363 Release of Information Code NU O ID 1/1

CLM10 1351 Patient Signature Source Code NU O ID 1/1

CLM11 C024 Related Causes Information S O

CLM11-01 1362 Related-Causes Code S 2/3 M ID 2/3

CLM11-02 1362 Related Causes Code S 2/3 O ID 2/3

CLM11-03 1362 Related Causes Code S 2/3 O ID 2/3

CLM11-04 156 State or Province Code NU O ID 2/2

CLM11-05 26 Country Code NU O ID 2/3

CLM12 1366 Special Program Code NU O ID 2/3


CLM14 1338 Level of Service Code NU O ID 1/3


CLM16 1360 Provider Agreement Code NU O ID 1/1

CLM17 1029 Claim Status Code NU O ID 1/2

CLM18 1073 Yes/No Condition or Response NU O/Z ID 1/1

CLM19 1383 Claim Submission Reason Code NU O ID 2/2

CLM20 1514 Delay Reason Code NU O ID 1/2


October 31, 2007 73

ELEMENT SUMMARY

CLM01 Patient Account Number

Identifier used to track a claim from creation by the health care provider through payment

Paper Form Equivalent: UB BOX #3.

Defaults to Value “ UNKNOWN”

CLM02 Total Charges Monetary amount

For Medicare, Non-Medicare, and Medicaid: Paper form equivalent UB Box #47 Revenue code 001. If calculated value of line items is not equivalent to paper form, defaults to value of calculated amount. If any line item contains critical default value of “0” defaults to value from paper form UB Box #47 with revenue code 001. For MSN, and MSN dup calculate total charges from line items: Defaults to value of Medicare paid amount in Notes or current part-A deductible amount. When no line items or total charge amounts are present Critical default value is “0” When critical default value is used, 2300 NTE01 is set to “CD Amt”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID

CLM03 Claim Filing Indicator Code

Code identifying type of claim

Not Used

CLM04 Non- Institutional Claim Type Code Code identifying the type of provider or claim

Not Used

CLM05 Bill Type

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

CLM05-01 Facility Code Value Code identifying the type of facility where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format

Paper Form Equivalent: UB BOX #4. Ignore leading zero if 4 digits.

For Medicare, Medicaid, and Non-Medicare, If not present or unavailable default to “11” if UB BOX #42 value is 100 -219. If not present or unavailable default to “21” if UB BOX # 42 value is 191 (Skilled Nursing). If not present or unavailable default to “13” if UB BOX #42 value is other than above, except for MSN inpatient and skilled nursing. For MSN default to “11” if an inpatient note exists unless Skilled Nursing Facility is mentioned in the Note, then default to “21”. All MSN dups and other MSNs default to “13”.

CLM05-02 Facility Code Qualifier

Code identifying the type of facility referenced

CODE DEFINITION A Uniform Billing Claim Form Bill Type --------- Defaults to “A”


October 31, 2007 74

CLM05-03 Claim Frequency Type Code Code specifying the frequency of the claim; this is the third position of the Uniform billing Claim Form Bill Type


Defaults to value “1”

CLM06 Yes/No condition or Response Code

Code indicating a Yes or No condition or response

Not Used

CLM07 Provider Accept Assignment Code Code indicating whether the provider accepts assignment

Not Used

CLM08 Assignment of Benefits Indicator Yes/No


CODE DEFINITION N No Y Yes

Paper Form Equivalent: UB BOX #53 A. For Medicare and Non-Medicare defaults to value “Y” For Medicaid always defaults to value “Y” For MSN search for note indicating assignment -- default to value “N”. MSN dup always defaults to value “N”

CLM09 Release of Information Code Code indicating whether the provider has on files a signed statement by the patient authorizing the release of medical data to other organizations

Not Used

CLM10 Patient Signature Source Code

Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider

Not Used

CLM11 Related Causes Information To identify one or more related causes and associated state or country information Following conversion table will be used for translation, 01,02,03 - AA 04 - EM, 05-OA

Required if codes 01, 04 and/or 05 are present on Paper Form Paper Form Equivalent: UB BOX #32-35

CODE DEFINITION X12-CODE 01 Auto Accident AA 04 Employment EM 05 Other Accident OA

CLM11-01 Related-Causes Code

Code identifying an accompanying cause of an illness, injury or an accident

CODE DEFINITION AA Auto Accident EM Employment OA Other Accident

CLM11-02 Related-Causes Code

Code identifying an accompanying cause of an illness, injury or an accident

CODE DEFINITION AA Auto Accident EM Employment


October 31, 2007 75

OA Other Accident

This element is required when an additional related cause Code is applicable. Related cause code must not be duplicated.

CLM11-03 Related-Causes Code Code identifying an accompanying cause of an illness, injury or an accident

CODE DEFINITION AA Auto Accident EM Employment OA Other Accident

This element is required when an additional Related Cause Code is applicable. Related cause code must not be duplicated.

CLM11-04 State or Province Code


Not Used

CLM11-05 Country Code Code identifying the country

Not Used

CLM12 Special Program Code

Code indicating the special Program under which the services rendered to the patient were performed

Not Used

CLM13 Yes/No Condition or Response Code Code indicating a Yes or No condition or response

Not Used

CLM14 Level of Service Code

Code specifying the level of service rendered

Not Used

CLM15 Yes/No Condition or Response Code Code indicating a Yes or No condition or response

Not Used

CLM16 Provider Agreement Code

Code indicating the type of agreement under which the provider is submitting this claim

Not Used

CLM17 Claim Status Code Code identifying the status of an entire claim as assigned by the payer, claim review organization or re-pricing organization

Not Used

CLM18 Yes/No Condition or Response Code


Not Used

CLM19 Claim Submission Reason Code Code identifying reason for claim submission

Not Used


October 31, 2007 76

CLM20 Delay Reason Code

Code indicating the reason why a request was delayed

Not Used


October 31, 2007 77

IMPLEMENTATION

DTP STATEMENT DATES Loop: 2300 - Claim Information Usage: REQUIRED Repeat: 1 Example: DTP*434*RD8*19981209-19981214~ DTP*434*D8*20050505~

STANDARD

DTP Date or Time or Period Level: Detail

Position: 135 Loop: 2300

Requirement: Optional Max Use: 150 Purpose: To specify any or all of a date, a time, or a time period Semantic: 02 DTP02 is the date or time or period format that will appear in DTP03.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

DTP01 374 Date/Time Qualifier R 3/3 M ID 3/3

DTP02 1250 Date Time Period Format Qualifier R 2/3 M/Z ID 2/3

DTP03 1251 Date Time Period R 1/35 M AN 1/35

ELEMENT SUMMARY

DTP01 Date/Time Qualifier

Code specifying type of date or time, or both date and time

CODE DEFINITION 434 Statement

DTP02 Date Time Period Format Qualifier

Code indicating the date format, time format, or date and time format Data Conversion Vendor hard codes this element to “RD8” with a range of dates

CODE DEFINITION D8 Date Expressed in the Format CCYYMMDD --- Defaults to “D8” RD8 Range of Dates expressed in the Format CCYYMMDD-CCYYMMDD

Data Conversion Vendor will select the qualifier based on the paper form date format

DTP03 Statement Date Time Period Expression of a date, a time, or range of dates, times or dates and times For Non-Medicare and Medicaid Paper Form Equivalent: UB BOX #6a & 6b. For Medicare statement dates are found on the Medicare EOB.


October 31, 2007 78

Critical default value is “01/01/current year”. When critical default value is used, 2300 NTE01 is set to “CD Date”, and 1000A NM109-Submitter ID value is set to Other Submitter ID


October 31, 2007 79

IMPLEMENTATION

DTP ADMISSION DATE Loop: 2300 - Claim Information Usage: SITUATIONAL Repeat: 1 Situational Rule: Required if necessary to meet specific Trading Partner data requirements. Notes: Example: DTP*435*DT*199610131242~

STANDARD

DTP Date or Time or Period



DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes




ELEMENT SUMMARY



CODE DEFINITION 435 Admission



CODE DEFINITION DT Date Expressed in the Format CCYYMMDDHHMM

DTP03 Admission Date Time Period


Replicate from the earliest Statement Date


October 31, 2007 80

IMPLEMENTATION

CL1 INSTITUTIONAL CLAIM CODE

Loop: 2300 - Claim Information Usage: REQUIRED Repeat: 1 Notes:

Example: CL1***01~

STANDARD

CL1 Claim Codes Level: Detail

Position: 140 Loop: 2300

Requirement: Optional Max Use: 1 Purpose: To supply information specific to hospital claims.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

CL101 1315 Admission Type Code NU O ID 1/1

CL102 1314 Admission Source Code NU O ID 1/1

CL103 1352 Patient Status Code R O ID 1/2

CL104 1345 Nursing Home Residential Status Code NU O ID 1/1

ELEMENT SUMMARY

CL101 Admission Type Code Code indicating the priority of this admission

Not Used

CL102 Admission Source Code

Code indicating the source of this admission

Not Used

CL103 Patient Discharge Status Code Code indicating patient status as of the “statement covers through date”

Paper Form Equivalent: UB92 BOX #22; UB04 BOX #17

For Non Medicare, Medicare, and Medicaid defaults to value “01” if unreadable or unavailable

For MSN, and MSN dup always defaults to value “01”

CL104 Nursing Home Residential status Code

Code specifying the status of a nursing home resident at the time of service

Not Used


October 31, 2007 81

IMPLEMENTATION

PWK CLAIM SUPPLEMENTAL INFORMATION

Loop: 2300 - Claim Information Usage: SITUATIONAL Repeat: 10 Situational Rule: Required when attachments are present Example: PWK*OZ~

STANDARD

PWK Paperwork


Requirement: Optional Max Use: 10 Purpose: To identify the type or transmission or both of paperwork or supporting information Syntax: 05 P0506 – If either PWK05 or PWK06 is present, then the other is required. Comments: 05 PWK05 and PWK06 may be used to identify the addressee by a code number.

07 PWK07 may be used to indicate special information to be shown on the specified report. 08 PWK08 may be used to indicate action pertaining to a report.

DIAGRAM

SEQ. NO.

REF. NO.

ASC X12 NAME

SF

REQ.

ASC X12 ATTRIBUTES

PWK01 755 Report Type Code R 2/2 M ID 2/2

PWK02 756 Report Transmission Code NU O ID 1/2

PWK03 757 Report Copies Needed NU O NO 1/ 2

PWK04 98 Entity Identifier Code NU O ID 2/3

PWK05 66 Identification Code Qualifier NU X ID ½

PWK06 67 Identification Code NU X AN 2/80

PWK07 352 Description NU O AN 1/80

PWK08 C002 Actions Indicated NU O

PWK09 1525 Request Category Code NU O ID 1/ 2


October 31, 2007 82

ELEMENT SUMMARY

PWK01 Report Type Code

Code indicating the title or contents of a document, report or supporting item

CODE DEFINITION OZ Support Data For Claim

PWK02 Report Transmission Code

Code defining timing, transmission method or format by which reports are to be sent

Not Used

PWK03 Report Copies Needed The number of copies of a report that should be sent to the addressee

Not Used

PWK04 Entity Identifier Code


Not Used

PWK05 Identification Code Qualifier Code designating the system/method of code structure used for identification Code (67)

Not Used

PWK06 Identification Code


Not Used

PWK07 Description A free-form description to clarify the related data elements and their content

Not Used

PWK08 Actions Indicated

Actions to be performed on the piece of paperwork identified

Not Used

PWK09 Request Category Code Code indicating a type of request

Not Used


October 31, 2007 83

IMPLEMENTATION

REF ADJUSTED REPRICED CLAIM NUMBER

Loop: 2300 - Claim Information Usage: SITUATIONAL Repeat: 1 Situational Rule: Required if necessary to meet specific Trading Partner data requirements. Notes: Example: REF*9C*GTF67354~

STANDARD






DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes












October 31, 2007 84

ELEMENT SUMMARY



CODE DEFINITION 9C Adjusted Re-priced Claim Reference Number



Identifies the Adjusted Re-priced Claim Number


Not Used



Not Used

REF04-01Reference Identification Qualifier Code qualifying the Reference Identification

Not Used

REF04-02Reference Identification


Not Used


Not Used



Not Used


Not Used



Not Used


October 31, 2007 85

IMPLEMENTATION

REF REPRICED CLAIM NUMBER

Loop: 2300 - Claim Information Usage: SITUATIONAL Repeat: 1

Situational Rule: Required if necessary to meet specific Trading Partner data requirements. Notes: Example: REF*9A*223367354~

STANDARD






DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes












October 31, 2007 86

ELEMENT SUMMARY



CODE DEFINITION 9A Re-priced Claim Reference Number



Identifies the Re-priced Claim Number


Not Used



Not Used


Not Used



Not Used

REF04-03 Reference Identification Qualifier Code qualifying the Reference Identification

Not Used



Not Used


Not Used



Not Used


October 31, 2007 87

IMPLEMENTATION

REF VENDOR TRACE NUMBER

Loop: 2300 - Claim Information Usage: REQUIRED Repeat: 1 Example: REF*D9*78302323DYTABES~

STANDARD






DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes












October 31, 2007 88

ELEMENT SUMMARY



CODE DEFINITION D9 Claim Number



Trace Number of the scanned image. Data Conversion Vendor will limit the length to 20 characters

REF03 Description


Not Used


Not Used



Not Used


Not Used



Not Used


Not Used



Not Used


Not Used


October 31, 2007 89

IMPLEMENTATION

REF ORIGINAL REFERENCE NUMBER (ICN/DCN)

Loop: 2300 - Claim Information Usage: SITUATIONAL Repeat: 1 Situational Rule: Required if necessary to meet specific Trading Partner data requirements. Example: REF*F8*123456768~

STANDARD






DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes












October 31, 2007 90

ELEMENT SUMMARY



CODE DEFINITION F8 Original Reference Number



aka, State Farm Bill ID


Not Used



Not Used


Not Used



Not Used


Not Used



Not Used


Not Used



Not Used


October 31, 2007 91

IMPLEMENTATION

NTE VENDOR NOTE


Situational Rule: Required when the Trading Partner has a need to identify any problems or issues encountered in the data conversion process.

Example: NTE*ADD*NR 6; UB EOB Non-Covered Charges; NR 14~

STANDARD

NTE Note/Special Instruction


Requirement: Optional Max Use: 20 Purpose: To transmit information in a free-form format, if necessary, for comment or special

instruction Comments: 00 The NTE segment permits free-form information/data, which under ANSI

X12 standard implementations, can not be machine processed. The use of the NTE segment should therefore be avoided, if at all possible, in an automated environment.

DIAGRAM

Seq. No. Ref.

No. ASC X12 Name SF


NTE01 363 Note Reference Code R 3/3 O ID 3/3

NTE02 352 Description R 1/80 M AN 1/80


October 31, 2007 92

ELEMENT SUMMARY

NTE01 Note Reference Code

Code identifying the functional area or purpose for which the note applies

CODE DEFINITION ADD Additional Information

NTE02 Description


CODE DEFINITION NA Not Available NR Not Readable OT Other UB Unbalanced CD Critical Default

Data Conversion vendor will populate NTE02 with one of the above listed codes in position 1-2. For all codes except CD the code will be followed by UB “BOX #” followed by next element delimited by a ';', if any non-standard elements were added or used.

For CD the code will be followed by Date, Amt, Rev, Prov, and/or Ded-coins followed by next element delimited by a “;”, if any critical default values were added or used.

If the entire 80 positions of the NTE segment are used, follow it with another instance of the NTE segment and so on.


October 31, 2007 93

IMPLEMENTATION

HI PRINCIPAL ADMITTING E-CODE AND PATIENT REASON FOR VISIT DIAGNOSIS INFORMATION

Loop: 2300 - Claim Information Usage: REQUIRED Repeat: 1 Example: HI*BK:2376*BJ:343222*BN:564456~

STANDARD

HI Health Care Information Codes


Requirement: Optional Max Use: 25 Purpose: To supply information related to the delivery of health care Syntax: 03 P0304 – If either C02203 or C02204 is present, then the other is required. Semantic: 01 C022-01 qualifies C022-02, C022-04, C022-05 and C022-06.

03 C022-03 is the date format that will appear in C022-04. 07 C022-07 qualifies C022-01.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

HI01 C022 Health Care Code Information R M

HI1-01 1270 Code List Qualifier Code R 1/3 M ID 1/3

HI1-02 1271 Industry Code R 1/30 M AN 1/30

HI1-03 1250 Date Time Period Format Qualifier NU X/Z ID 2/3

HI1-04 1251 Date Time Period NU X AN 1/35

HI1-05 782 Monetary Amount NU O R 1/18

HI1-06 380 Quantity NU O R 1/15

HI1-07 799 Version Identifier NU O/Z AN 1/30

HI02 C022 Health Care Code Information S O







October 31, 2007 94











HI04 C022 Health Care Code Information NU O









ELEMENT SUMMARY

HI01 Health Care Code Information

To send health care codes and their associated dates, amounts and quantities


HI01-01 Code list Qualified Code Code identifies an industry specific code.

CODE DEFINITION BK Principal Diagnosis

HI01-02 Industry Code

Code indicating a code from a specific industry code list

Paper Form Equivalent: UB BOX #69. Defaults to value “UNKNOWN”

HI01-03 Date Time Period Format Qualifier


Not Used


October 31, 2007 95

HI01-04 Date Time Period


Not Used

HI01-05 Monetary Amount Monetary amount

Not Used

HI01-06 Quantity


Not Used

HI01-07 Version Identifier Revision level of a particular format, program, technique or algorithm

Not Used



Required if present on paper form Paper Form Equivalent: UB BOX #69.

HI02-01 Code list Qualifier Code

Code identifies an industry specific code.

CODE DEFINITION BJ Admitting Diagnosis


Code indicating a code from a specific industry code list Required if present on paper form Paper Form Equivalent: UB BOX #69



Not Used

HI02-04 Date Time Period Expression of a date, a time, or range of dates, times or dates and times

Not Used

HI02-05 Monetary Amount

Monetary amount

Not Used

HI02-06 Quantity Numeric value of quantity

Not Used

HI02-07 Version Identifier

Revision level of a particular format, program, technique or algorithm

Not Used


October 31, 2007 96




HI03-01 Code list Qualifier Code Code identifies an industry specific code.

CODE DEFINITION BN United States Department of Health and Human Services, Office of Vital Statistics E-Code






Not Used


Not Used


Monetary amount

Not Used


Not Used



Not Used


Not Used


Not Used


Not Used


October 31, 2007 97


Not Used


Not Used


Not Used


Not Used


Not Used


Not Used


October 31, 2007 98

IMPLEMENTATION

HI OTHER DIAGNOSIS INFORMATION


Situational Rule: Required when there are appropriate values that apply to this claim, and those values are legible. If not present or legible, do not send.

Example: HI*BF:V9782~ HI*BF:V8789*BF:T76786*BF:K87546*BF:L66565*BF:M235*BF:J5788*BF:X867*BF:Z445*~

STANDARD





DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes















October 31, 2007 99






































October 31, 2007 100




















ELEMENT SUMMARY



Required, if present on the paper form Paper Form Equivalent: UB BOX #67A.


CODE DEFINITION BF Diagnosis



Paper Form Equivalent: UB BOX #67A.

HI01-03 Date Time Period Format Qualifier Code indicating the date format, time format, or date and time format

Not Used



Not Used


October 31, 2007 101


Monetary amount

Not Used


Not Used



Not Used

HI02 Health Care Code Information To send health care codes and their associated dates, amounts and quantities

Required if present on paper form Paper Form Equivalent: UB BOX #67B-H.




Code indicating a code from a specific industry code list Required if present on paper form Paper Form Equivalent: UB BOX #67B-H.



Not Used


Not Used


Monetary amount

Not Used


Not Used



Not Used


October 31, 2007 102

HI03 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Required if present on paper form Paper Form Equivalent: UB BOX #67B-H.






Paper Form Equivalent: UB BOX #67B-H.


Not Used



Not Used


Not Used

HI03-06 Quantity


Not Used


Not Used











October 31, 2007 103


Not Used


Not Used


Monetary amount

Not Used


Not Used



Not Used










Not Used



Not Used


Not Used


October 31, 2007 104


Not Used



Not Used










Not Used



Not Used


Not Used

HI6-06 Quantity


Not Used


Not Used


October 31, 2007 105









Not Used



Not Used


Not Used

HI07-06 Quantity


Not Used


Not Used



Required if present on paper form Paper Form Equivalent: UB BOX #67B-H






Paper Form Equivalent: UB BOX #67B-H


October 31, 2007 106


Not Used



Not Used


Not Used

HI08-06 Quantity


Not Used


Not Used



Not Used


Not Used



Not Used


Not Used


October 31, 2007 107

IMPLEMENTATION

HI PRINCIPAL PROCEDURE INFORMATION



Example: HI*BP:92795:D8:19980321~ HI*BR:92795:D8:19980321~

STANDARD





DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes




HI1-03 1250 Date Time Period Format Qualifier S 2/3 X/Z ID 2/3

HI1-04 1251 Date Time Period S 1/35 X AN 1/35










October 31, 2007 108







ELEMENT SUMMARY



Principle Procedure Code Paper Form Equivalent: UB BOX #74.



CODE DEFINITION BP Health Care Financing Administration Common Procedural coding

System Principal Procedure BR International Classification of Diseases Clinical Modification (ICD-9-CM) Principle Procedure

DCV Defaults to Value “BR”





CODE DEFINITION D8 Date expressed in Format CCYYMMDD.





Not Used

HI01-06 Quantity


Not Used


October 31, 2007 109


Not Used



Not Used


Not Used



Not Used


Not Used



Not Used


Not Used



Not Used


Not Used



Not Used


Not Used


Not Used


October 31, 2007 110

IMPLEMENTATION

HI OTHER PROCEDURE INFORMATION



Example: HI*BO:92795:D8:19980321*BQ:4534:D8:20050505*BO:9834:D8:20010101*BQ:24243:D8:19990909~

STANDARD





DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes
















October 31, 2007 111







HI3-04 1251 Date Time Period S X AN 1/35




























October 31, 2007 112

ELEMENT SUMMARY


To send health care codes and their associated dates, amounts and quantities Required if present on paper form Paper Form Equivalent: UB BOX #74A.



CODE DEFINITION BO Health Care Financing Administration Common Procedural Coding System BQ International Classification of Diseases (ICD-9-CM) Procedure

DCV Defaults to Value “BQ”





CODE DEFINITION D8 Date Expressed in the Format CCYYMMDD





Not Used

HI01-06 Quantity


Not Used


Not Used



Required if present on paper form Paper Form Equivalent: UB BOX #74B-E






October 31, 2007 113



Paper Form Equivalent: UB BOX #74B-E





Paper Form Equivalent: UB BOX #74B-E


Not Used

HI02-06 Quantity


Not Used


Not Used



Required if present on paper form Paper Form Equivalent: UB BOX #74B-E.



CODE DEFINITION BO Health Care Financing Administration Common Procedural Coding

System BQ International Classification of Diseases (ICD-9-CM) Procedure




Paper Form Equivalent: UB BOX #74B-E.







October 31, 2007 114


Monetary amount

Not Used


Not Used



Not Used


Required if present on paper form Paper Form Equivalent: UB BOX #74B-E.



CODE DEFINITION BO Health Care Financing Administration Common Procedural Coding System4 BQ International Classification of Diseases (ICD-9-CM) Procedure











Not Used

HI04-06 Quantity


Not Used


Not Used


October 31, 2007 115


Required if present on paper form Paper Form Equivalent: UB BOX #81E.







Paper Form Equivalent: UB BOX #81E.





Paper Form Equivalent: UB BOX #81E.


Not Used

HI05-06 Quantity


Not Used


Not Used


Not Used


Not Used


Not Used


October 31, 2007 116


Not Used


Not Used


Not Used


Not Used


October 31, 2007 117

IMPLEMENTATION

HI OCCURRENCE INFORMATION



Example: HI*BH:42:D8:19981208~

HI*BH:92795:D8:19980321*BH:4534:D8:20050505*BH:9834:D8:20010101*BH:24243:D8:19990909 *BH:92365:D8:19990421*BH:4454:D8:20050404*BH:9564:D8:20030303*BH:34603:D8:20041212~

STANDARD





DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes



HI1-02 1271 Industry Code R1/30 M AN 1/30

HI1-03 1250 Date Time Period Format Qualifier R 2/3 X/Z ID 2/3

HI1-04 1251 Date Time Period R 1/35 X AN 1/35







October 31, 2007 118






































October 31, 2007 119
























October 31, 2007 120

ELEMENT SUMMARY


To send health care codes and their associated dates, amounts and quantities Required if present on paper form. Paper Form Equivalent: UB BOX #32-35.



CODE DEFINITION BH Occurrence



Paper Form Equivalent: UB BOX #32-35.

Defaults to Value “UNKNOWN” HI01-03 Date Time Period Format Qualifier







Not Used

HI01-06 Quantity


Not Used


Not Used



Required if present on paper form Paper Form Equivalent: UB BOX #32-35.





October 31, 2007 121










Not Used

HI02-06 Quantity


Not Used


Not Used



Required if present on paper form Paper Form Equivalent: UB BOX #32-35.













Not Used


October 31, 2007 122

HI03-06 Quantity


Not Used


Not Used



Required if present on paper form Paper Form Equivalent: UB BOX #32-35













Not Used

HI04-06 Quantity


Not Used


Not Used








October 31, 2007 123










Not Used

HI05-06 Quantity


Not Used


Not Used
















Not Used


October 31, 2007 124

HI06-06 Quantity


Not Used


Not Used
















Not Used

HI07-06 Quantity


Not Used


Not Used








October 31, 2007 125










Not Used

HI08-06 Quantity


Not Used


Not Used


Not Used


Not Used


Not Used


Not Used


October 31, 2007 126

IMPLEMENTATION

HI VALUE INFORMATION

Loop: 2300 - Claim Information Usage: SITUATIONAL Repeat: 2 Situational Rule: Required when there is a value code that applies to the claim. Notes: If the Value code is unreadable key "UNKNOWN" and the dollar amount

If the Value code is readable and the amount is blank or unreadable key the amount as 0 (ZERO) If duplicate 01, 06, A1, A2 codes exist default to first code and amount.

Example: HI*BE:08:::1740~ HI*BE:01:::0120*BE:02:::0230*BE:03:::0340*BE:04:::0440*BE:05:::0505*BE:06:::0640*BE:07:::0740*BE:08:::0840*BE:09:::0980*BE:10:::1040*BE:11:::1140*BE:12:::1240~

STANDARD





DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes






HI1-05 782 Monetary Amount R 1/18 O R 1/18








October 31, 2007 127






































October 31, 2007 128






































October 31, 2007 129













ELEMENT SUMMARY



Required if present on paper form Paper Form Equivalent: UB BOX #39A.



CODE DEFINITION BE Value





Not Used



Not Used



HI01-06 Quantity


Not Used


October 31, 2007 130



Not Used


Required if present on paper form Paper Form Equivalent: UB BOX #39B.






Paper Form Equivalent: UB BOX #39B.


Not Used



Not Used



HI02-06 Quantity


Not Used


Not Used



Required if present on paper form Paper Form Equivalent: UB BOX #39C.






Paper Form Equivalent: UB BOX #39C.


October 31, 2007 131



Not Used


Not Used


Monetary amount

Paper Form Equivalent: UB BOX #39C. HI03-06 Quantity


Not Used


Not Used



Required if present on paper form Paper Form Equivalent: UB BOX #39D.






Paper Form Equivalent: UB BOX #39D. HI04-03 Date Time Period Format Qualifier


Not Used


Not Used


Monetary amount

Paper Form Equivalent: UB BOX #39D.


Not Used


October 31, 2007 132


Not Used



Required if present on paper form Paper Form Equivalent: UB BOX #40A






Paper Form Equivalent: UB BOX #40A


Not Used



Not Used


Paper Form Equivalent: UB BOX #40A

HI05-06 Quantity


Not Used


Not Used








October 31, 2007 133

HI06-02 Industry Code Code indicating a code from a specific industry code list

Paper Form Equivalent: UB BOX #40B



Not Used HI06-04 Date Time Period


Not Used


Paper Form Equivalent: UB BOX #40B

HI06-06 Quantity


Not Used


Not Used









Paper Form Equivalent: UB BOX #40C HI07-03 Date Time Period Format Qualifier


Not Used


Not Used


Monetary amount

Paper Form Equivalent: UB BOX #40C


October 31, 2007 134


Not Used



Not Used








Paper Form Equivalent: UB BOX #40D


Not Used



Not Used


Paper Form Equivalent: UB BOX #40D

HI08-06 Quantity


Not Used


Not Used


October 31, 2007 135



Required if present on paper form Paper Form Equivalent: UB BOX #41A.






Paper Form Equivalent: UB BOX #41A. HI09-03 Date Time Period Format Qualifier


Not Used


Not Used


Monetary amount



Not Used



Not Used










October 31, 2007 136



Not Used HI10-04 Date Time Period


Not Used HI10-05 Monetary Amount

Monetary amount



Not Used



Not Used










Not Used



Not Used




Not Used


October 31, 2007 137



Not Used










Not Used



Not Used



HI12-06 Quantity


Not Used


Not Used


October 31, 2007 138

IMPLEMENTATION

HCP CLAIM PRICING/REPRICING INFORMATION

Loop: 2300 - Claim Information Usage: SITUATIONAL Repeat: 1 Situational Rule: This segment is required for PPO re-pricing. Notes: This segment should not be used by Data Conversion Vendor. Example: HCP*03*200~ HCP*03*100*10*RPO12345~

STANDARD

HCP Health Care Pricing


Requirement: Optional Max Use: 1 Purpose: To specify pricing or re-pricing information about a health care claim or line item Syntax: 01 R0113 – At least one of HCP01 or HCP13 is required.

09 P0910 – If either HCP09 or HCP10 is present, then the other is required. 11 P1112 – If either HCP11 or HCP12 is present, then the other is required.

Semantic: 02 HCP02 is the allowed amount. 03 HCP03 is the savings amount. 04 HCP04 is the re-pricing organization identification number. 05 HCP05 is the pricing rate associated with per diem or flat rate re-pricing. 06 HCP06 is the approved DRG code. 07 HCP07 is the approved DRG amount. 08 HCP08 is the approved revenue code. 10 HCP10 is the approved procedure code. 12 HCP12 is the approved service units or inpatient days. 13 HCP13 is the rejection message returned from the third party organization. 15 HCP15 is the exception reason generated by a third party organization.

Comments: 06 HCP06, HCP07, HCP08, HCP10 and HCP12 are fields that will contain different values from the original submitted values.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

HCP01 1473 Pricing Methodology R 2/2 X ID 2/2

HCP02 782 Monetary Amount R 1/18 O/Z R 1/18

HCP03 782 Monetary Amount S 1/18 O/Z R 1/18

HCP04 127 Reference Identification S 1/30 O/Z AN 1/30

HCP05 118 Rate S 1/9 O/Z R 1/9



October 31, 2007 139


HCP08 234 Product/Service ID S 1/48 O/Z AN 1/48

HCP09 235 Product/Service ID Qualifier S 2/2 X ID 2/2


HCP11 355 Unit or Basis for Measurement Code S 2/2 X ID 2/2

HCP12 380 Quantity S 1/15 X/Z R 1/15

HCP13 901 Reject Reason Code S 2/2 X/Z ID 2/2

HCP14 1526 Policy Compliance Code S 1/ 2 O ID 1/2

HCP15 1527 Exception Code S 1/ 2 O/Z ID 1/2

ELEMENT SUMMARY

HCP01 Pricing Methodology

Code specifying pricing methodology at which the claim or line item has been priced or re-priced.

CODE DEFINITION 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard fee schedule 03 Priced at a contractual percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing

HCP02 Monetary Amount

Monetary amount

Re-priced allowed amount

HCP03 Monetary Amount Monetary amount

This data element is required when it is necessary to report savings Amount on claims, which has been priced or re-priced.

HCP04 Reference Identification


This data element is required when it is necessary to report Re-pricing Organization ID on claims, which has been priced or Re-priced.


October 31, 2007 140

HCP05 Rate Rate expressed in the standard monetary denomination for the currency specified

This data element is required when it is necessary to report Pricing Rate on claims which has been priced or re-priced.



This data element is required when it is necessary to report Approved DRG Code on claims, which has been priced or re-priced.


Monetary amount

This data element is required when it is necessary to report Approved DRG Amount on claims, which has been priced or Re-priced.

HCP08 Product/Service ID

Identifying number for a product or service

This data element is required when it is necessary to report Approved Revenue Code on claims, which has been priced or Re-Priced.

HCP09 Product/Service ID Qualifier

Code identifying the type/source of the descriptive number used in Product/Service ID 234)

CODE DEFINITION HC Health Care Financing Administration Common Procedural

Coding System (HCPCS) Code

HCP10 Product/Service ID Identifying number for a product or service


HCP11 Unit or Basis for Measurement Code

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

CODE DEFINITION DA Days UN Unit

HCP12 Quantity

Numeric value of quantity Identifying number for a product or service



October 31, 2007 141

HCP13 Reject Reason Code Code assigned by issuer to identify reason for rejection

CODE DEFINITION T1 Can Not Identify Provider as TPO (Third party Organization) Participant T2 Can Not Identify Payer as TPO (Third party Organization) Participant T3 Can Not Identify Insured as TPO (Third party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for-pricing This data element is required when it is necessary to report Rejection Message on claims which has been priced or re-priced.

HCP14 Policy Compliance Code Code specifying policy compliance

CODE DEFINITION 1 Procedure Followed 2 Not Followed- Call Not made (Non Compliance Call Not Made) 3 Not Medically Necessary (Non Compliance Non Medically Necessary) 4 Not Followed Other (Non Compliance Other) 5 Emergency Admit to Non-Network Hospital

This data element is required when it is necessary to report Policy Compliance Code on claims which has been priced or re-priced

HCP15 Exception Code

Code specifying the exception reason for consideration of out-of-network health care services.

CODE DEFINITION 1 Non-Network Institutional Provider in Network hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other

This data element is required when it is necessary to report Exception Reason Code on claims which have been priced or Re-priced.


October 31, 2007 142

IMPLEMENTATION

SBR OTHER SUBSCRIBER INFORMATION

Loop: 2320 – Other Subscriber Information Usage: SITUATIONAL Repeat: 1 Situational Rule: Required when other payers are involved in paying this claim. Notes: This segment will always be present for Medicaid, Medicare, Medigap and MSN. Example: SBR*S~ SBR*U~

STANDARD

SBR Subscriber Information


Requirement: Optional Max Use: 1 Purpose: To record information specific to the primary insured and the insurance carrier that insured Semantic: 02 SBR02 specifies the relationship to the person insured..

03 SBR03 is policy or group number. 04 SBR04 is plan name. 07 SBR07 is destination payer code. A “Y” value indicates the payer is the destination

payer, an “N” value indicates the payer is not the destination payer.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

SBR01 1138 Payer Responsibility Sequence Number Code R 1/1 M ID 1/1

SBR02 1069 Individual Relationship Code NU O/Z ID 2/2

SBR03 127 Reference Identification NU O/Z AN 1/30

SBR04 93 Name NU O/Z AN 1/60

SBR05 1336 Insurance Type Code NU O ID 1/3

SBR06 1143 Coordination of Benefits Code NU O ID 1/1

SBR07 1073 Yes/No Condition or Response Code NU O/Z ID 1/1

SBR08 584 Employment Status Code NU O ID 2/2

SBR09 1032 Claim Filing Indicator Code NU O ID 1/2


October 31, 2007 143

ELEMENT SUMMARY

SBR01 Payer Responsibility Sequence Number Code

Code identifying the insurance carrier’s level of responsibility for a payment of a claim

Value must be set to "U" for Non-Medicare Value must be set to "S" for Medicaid, Medicare, Medigap or MSN

CODE DEFINITION S Secondary U Unknown

SBR02 Individual Relationship Code

Code indicating the relationship between two individuals or entities

Not Used

SBR03 Reference Identification Reference information as defined for a particular Transaction set or as specified by the Reference identification Qualifier

Not Used

SBR04 Name

Free-form name

SBR05 Insurance Type Code Code identifying the type of insurance policy within a specific insurance program

Not Used

SBR06 Coordination of Benefits Code

Code identifying whether there is a coordination of benefits

Not Used

SBR07 Yes/No Condition or Response Code Code indicating a Yes or No condition or response

Not Used

SBR08 Employment Status Code

Code showing the general employment status of an employee/claimant

Not Used

SBR09 Claim Filing Indicator Code Code identifying type of claim

Not Used


October 31, 2007 144

IMPLEMENTATION

CAS CLAIM LEVEL ADJUSTMENT

Loop: 2320 – Other Subscriber Information Usage: SITUATIONAL Repeat: 5 Situational Rule: Required when the claim has been adjudicated by Medicare. Notes: 1.Refer to front matter section 1.6.7 & 1.6.8.

2. Only one group code is allowed per CAS. If it is necessary to send more than one group code at the claim level, repeat the CAS segment again.

3 Codes and associated amounts must come from Medicare EOB or MSN. 4 A single CAS segment contains six repetitions of the “adjustment duo” composed of adjustment reason code and adjustment amount. These six adjustment duos are used to report up to six adjustments related to a particular claim adjustment group code (CAS01). The First adjustment is reported in the first adjustment duo (CAS02- CAS03). If there is a second non-zero adjustment, it is reported in the second adjustment duo (CAS05-CAS06), and so on through the sixth adjustment duo (CAS17 – CAS18).

1 Example: CAS*CO*96*555.52~

STANDARD

CAS Claims Adjustment


Requirement: Optional Max Use: 99 Purpose: To supply adjustment reason codes and amounts as needed for an entire claim or for a

particular service within the claim being paid Syntax: 05 L050607 – If CAS05 is present, then at least one of CAS06 or CAS07 is required.

06 C0605 – If CAS06 is present, then CAS05 is required. 07 C0705 – If CAS07 is present, then CAS05 is required. 08 L080910 – If CAS08 is present, then at least one of CAS09 or CAS10 is required. 09 C0908 – If CAS09 is present, then CAS08 is required. 10 C1008 – If CAS10 is present, then CAS08 is required. 11 L111213 – If CAS11 is present, then at least one of CAS12 or CAS13 is required. 12 C1211 – If CAS12 is present, then CAS11 is required. 13 C1311 – If CAS13 is present, then CAS11 is required. 14 L141516 If CAS14 is present, then at least one of CAS15 or CAS16 is required. 15 C1514 – If CAS15 is present, then CAS14 is required. 16 C1614 – If CAS16 is present, then CAS14 is required. 17 L171819 – If CAS17 is present, then at least one of CAS18 or CAS19 is required. 18 C1817 – If CAS18 is present, then CAS17 is required. 19 C1917 – If CAS19 is present, then CAS17 is required.

Semantic: 03 CAS03 is the amount of adjustment. 04 CAS04 is the units of service being adjusted. 06 CAS06 is the amount of the adjustment. 07 CAS07 is the units of service being adjusted. 09 CAS09 is the amount of the adjustment. 10 CAS10 is the units of service being adjusted.


October 31, 2007 145

12 CAS12 is the amount of the adjustment. 13 CAS13 is the units of service being adjusted. 15 CAS15 is the amount of the adjustment. 16 CAS16 is the units of service being adjusted. 18 CAS18 is the amount of the adjustment. 19 CAS19 is the units of service being adjusted.

Comments: 00 Adjustment information is intended to help the provider balance the

remittance information. Adjustment amounts should fully explain the difference between submitted charges and the amount paid. 03 When the submitted charges are paid in full, the value for CAS03 should be zero.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

CAS01 1033 Claim Adjustment Group Code R 1/2 M ID 1/2

CAS02 1034 Claim Adjustment Reason Code R 1/5 M ID 1/5

CAS03 782 Monetary Amount R 1/18 M/Z R 1/18

CAS04 380 Quantity NU O/Z R 1/15

CAS05 1034 Claim Adjustment Reason Code S 1/5 X ID 1/5

CAS06 782 Monetary Amount S 1/18 X/Z R 1/18

CAS07 380 Quantity NU X/Z R 1/15














October 31, 2007 146

ELEMENT SUMMARY

CAS01 Claim Adjustment Group Code

Code identifying the general category of payment adjustment

CODE DEFINITION CO Contractual Obligations (all other adjustments) OA Other Adjustments CR Corrections and Reversals PI Payer Initiated Reductions PR Patient Responsibility (Deductible, Coinsurance, Blood deductible, and

Lifetime reserve)

Paper form Equivalent: Medicare EOB, and MSN

Key the value present on the paper form. Otherwise, default to value PR for deductible, coinsurance and blood deductible or default to value CO for all other adjustments

CAS02 Claim Adjustment Reason Code

Code identifying the detailed reason the adjustment was made

CODE SOURCE 139: Claim Adjustment Reason Code


If adjustment amount is present and reason code is unknown defaults to value “A2”

CAS03 Monetary Amount Monetary amount


If Deductible and Coinsurance is not available or either is unreadable then the Critical default value is “0”. When critical default value is used, 2320 NTE01 is set to “CD DED-COINS”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID

For all other Claim adjustment reason codes defaults to value ZERO

CAS04 Quantity


Not Used

CAS05 Claim Adjustment Reason Code Code identifying the detailed reason the adjustment was made





October 31, 2007 147

CAS06 Monetary Amount

Monetary amount

Required if present on paper form Paper form Equivalent: Medicare EOB, and MSN



CAS07 Quantity


Not Used

CAS08 Claim Adjustment Reason Code Code identifying the detailed reason the adjustment was made CODE SOURCE 139: Claim Adjustment Reason Code




Monetary amount




CAS10 Quantity Numeric value of quantity

Not Used







October 31, 2007 148


Monetary amount





Not Used










CAS16 Quantity


Not Used

CAS17 Claim Adjustment Reason Code Code identifying the detailed reason the adjustment was made





October 31, 2007 149


Required if present on paper form Paper form Equivalent: Medicare EOB, and MSN.




Not Used


October 31, 2007 150

IMPLEMENTATION

AMT OTHER PAYER PRIOR PAID AMOUNT

Loop: 2320 – Other Subscriber Information Usage: SITUATIONAL Repeat: 1 Situational Rule: Required for Non-Medicare and Medicaid when an other payer paid amount exists. Notes: Example: AMT*C4*302.22~

STANDARD

AMT Monetary Amount


Requirement: Optional Max Use: 15 Purpose: To indicate the total monetary amount

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

AMT01 522 Amount Qualifier Code R 1/3 M ID 1/3

AMT02 782 Monetary Amount R 1/18 M R 1/18

AMT03 478 Credit/Debit Flag Code NU O ID 1/1

ELEMENT SUMMARY

AMT01 Amount Qualifier Code

Code to qualify amount

CODE DEFINITION C4 Prior payment Actual

AMT02 Monetary Amount

Monetary amount


AMT03 Credit/Debit Flag Code Code indicating whether amount is a credit or debit

Not Used


October 31, 2007 151

IMPLEMENTATION

AMT COORDINATION OF BENEFITS (COB) TOTAL ALLOWED AMOUNT

Loop: 2320 – Other Subscriber Information Usage: SITUATIONAL

Situational Rule: Required for all Medicare, and MSN. Repeat: 1 Example: AMT*B6*3794.82~

STANDARD

AMT Monetary Amount Level:Detail

Position:300 Loop:2320

Requirement:Optional Max Use: 15 Purpose:To indicate the total monetary amount

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes




ELEMENT SUMMARY



CODE DEFINITION B6 Allowed – Actual


Monetary amount

AMT Coordination of Benefits (COB) Total Allowed Amount: Paper Form Equivalent: Medicare EOB, aka “Allowed Amount”. Defaults to value calculated from coinsurance x 5 plus deductible.

AMT03 Credit/Debit Flag Code

Code indicating whether amount is a credit or debit Not Used


October 31, 2007 152

IMPLEMENTATION

AMT COORDINATION OF BENEFITS (COB) TOTAL MEDICARE PAID AMOUNT

Loop: 2320 – Other Subscriber Information Usage: SITUATIONAL Repeat: 1 Situational Rule: Required for Medicare when Medicare paid amount exists Example: AMT*N1*873.4~

STANDARD

AMT Monetary Amount



DIAGRAM

Seq. No. Ref.

No. ASC X12 Name SF





ELEMENT SUMMARY



CODE DEFINITION N1 Medicare Paid


Monetary amount

Paper Form Equivalent: Medicare EOB, and MSN aka "Net Medicare Reimbursement/Payment". For MSN: This amount may be located in the Notes section of the form.

AMT03 Credit/Debit Flag Code

Code indicating whether amount is a credit or debit

Not Used


October 31, 2007 153

IMPLEMENTATION

AMT COORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT

Loop: 2320 – Other Subscriber Information Usage: SITUATIONAL Repeat: 1 Situational Rule: Required for Medicare when Medicare paid amount exists Note: This segment is used only for Medicare Claims Example: AMT*A8*273~

STANDARD

AMT Monetary Amount



DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes




ELEMENT SUMMARY



CODE DEFINITION A8 Non-Covered Charges - Actual


Monetary amount

Paper Form Equivalent: Medicare EOB, aka "Non-Covered Charges"

AMT03 Credit/Debit Flag Code Code indicating whether amount is a credit or debit

Not Used


October 31, 2007 154

IMPLEMENTATION

MIA MEDICARE INPATIENT ADJUDICATION INFORMATION

Loop: 2320 – Other Subscriber Information Usage: SITUATIONAL Repeat: 1 Situational Rule: Required for Medicare, and MSN inpatient claims when information is present and legible. Example: MIA*1*2**3568.98~ MIA*0*0~ --- Defaults for Medicare and MSN

STANDARD

MIA Medicare Inpatient Adjudication


Requirement: Optional Max Use: 1 Purpose: To provide claim-level data related to the adjudication of Medicare inpatient claims Semantic: 01 MIA01 is the covered days.

02 MIA02 is the lifetime reserve days. 03 MIA03 is the lifetime psychiatric days. 04 MIA04 is the Diagnosis Related Group (DRG) amount. 05 MIA05 is the Claim Payment Remark Code. See Code Source 411. 06 MIA06 is the disproportionate share amount. 07 MIA07 is the Medicare secondary Payer (MSP) pass through amount. 08 MIA08 is the total Prospective Payment System (PPS) capital amount. 09 MIA09 is the Prospective Payment System (PPS) capital, federal specific

portion, Diagnosis Related Group (DRG) amount. 10 MIA10 is the Prospective Payment System (PPS) capital, hospital specific

portion, Diagnosis Related Group (DRG), amount. 11 MIA11 is the Prospective Payment System (PPS) capital, disproportionate

share, hospital Diagnosis Related Group (DRG) amount. 12 MIA12 is the old capital amount. 13 MIA13 is the Prospective Payment System (PPS) capital indirect medical

education claim amount. 14 MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. 15 MIA15 is the cost report days. 16 MIA16 is the federal specific Diagnosis Related Group (DRG) amount. 17 MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. 18 MIA18 is the indirect teaching amount. 19 MIA19 is the Institutional component amount billed but not payable. 20 MIA20 is the Claim Payment Remark Code. See Code Source 411. 21 MIA21 is the Claim Payment Remark Code. See Code Source 411. 22 MIA22 is the Claim Payment Remark Code. See Code Source 411. 23 MIA23 is the claim Payment Remark Code. See Code Source 411. 24 MIA24 is the capital exception amount.


October 31, 2007 155

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

MIA01 380 Quantity R 1/15 M/Z R 1/15

MIA02 380 Quantity S 1/15 O/Z R 1/15

MIA03 380 Quantity NU O/Z R 1/15

MIA04 782 Monetary Amount NU O/Z R 1/18

MIA05 127 Reference Identification NU O/Z AN 1/30










MIA15 380 Quantity NU O/Z R 1/15











October 31, 2007 156

ELEMENT SUMMARY

MIA01 Quantity


Paper Form Equivalent: Medicare EOB, aka "Covered Days" For MSN, aka “Benefit days used”


MIA02 Quantity

Numeric value of quantity Required if present on paper form Paper Form Equivalent: Medicare EOB, aka “Lifetime Reserve Days” For MSN: This amount may be located in the Notes section of the form.


MIA03 Quantity


Not Used

MIA04 Monetary Amount Monetary amount Not Used

MIA05 Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference identification Qualifier

Not Used

MIA06 Monetary Amount Monetary amount

Not Used

MIA07 Monetary Amount

Monetary amount

Not Used


Not Used


Monetary amount

Not Used


Not Used


October 31, 2007 157


Monetary amount

Not Used


Not Used


Not Used


Not Used

MIA15 Quantity Numeric value of quantity

Not Used


Not Used


Not Used


Not Used MIA19 Monetary Amount

Monetary amount

Not Used

MIA20 Reference Identification Reference information as defined for a particular Transaction Set or as specified by the Reference identification Qualifier

Not Used


Not Used


Not Used


Not Used


Not Used


October 31, 2007 158

IMPLEMENTATION

NM1 OTHER PAYER NAME Loop: 2330B – Other Payer Name Repeat: 1 Usage: SITUATIONAL Note: Repeat: 1 Situational Rule: Required for all Medicare, and Medicaid. For Non Medicare required when there are

appropriate values that apply to this claim. Notes: Don’t submit this loop, If ICN/DCN #s unreadable (REF) for UB-Medicare. Example: NM1*PR*2*Other Payer Name~

STANDARD

NM1 Individual or Organizational Name Level: Detail

Position: 325 Loop: 2330 Repeat: 10

Requirement: Optional Max Use: Purpose: To supply the full name of an individual or organizational entity.

Set Notes: 1. Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.



DIAGRAM

Seq. No. Ref.

No. ASC X12 Name SF









NM108 66 Identification Code Qualifier NU X ID 1/2

NM109 67 Identification Code NU X AN 2/80




October 31, 2007 159

ELEMENT SUMMARY



CODE DEFINITION PR Payer



CODE DEFINITION 2 Non Person Entity



Paper Form Equivalent: UB BOX #50. For Non Medicare set value to “Available” if any value other than State Farm, None, No other coverage, Self Pay, Individual, Repricer or PPO (see separate list of repricer names) is present in BOX #50 OR if a value is present in loop 2320 AMT02 OTHER PAYER PAID AMOUNT

Set value to “Medicare” for Medicare, MSN, and MSN dup Claims

Set value to “Medicaid” for Medicaid Claims NM104 Name First


Not Used

NM105 Name Middle Individual middle name or initial

Not Used

NM106 Name Prefix

Prefix to individual name

Not Used NM107 Name Suffix


Not Used NM108 Identification Code Qualifier

Code designating the system/method of code structure used for Identification Code (67) Not Used



Not Used


Not Used




October 31, 2007 160

Not Used

IMPLEMENTATION

REF OTHER PAYER (MEDICARE) SECONDARY

IDENTIFICATION AND REFERENCE NUMBER (ICN/DCN)

Loop: 2330B – Other Payer Name Usage: SITUATIONAL Repeat: 2 Situational Rule: This Segment is required for Medicare claims when present and legible. Notes: Example: REF*F8*123456768~

STANDARD






DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes












October 31, 2007 161

ELEMENT SUMMARY



CODE DEFINITION F8 Original Reference Number Internal Control Number (ICN) OR Document Control Number (DCN) Use to indicate the payer’s claim number for this claim for the payer identified in this iteration of the 2330B loop.



Paper Form Equivalent: Medicare EOB, MSN, and MSN dup, aka ICN or DCN or Claim Number.

REF03 Description


Not Used


Not Used



Not Used


Not Used



Not Used


Not Used



Not Used


Not Used


October 31, 2007 162

IMPLEMENTATION

LX SERVICE LINE NUMBER

Loop: 2400 – Service Line Number Repeat : 999 Usage: REQUIRED Repeat: 1 Example: LX*1~

STANDARD

LX Assigned Number

Level: Detail Position: 365 Loop: 2400 Repeat >1

Requirement: Optional Max Use: 1 Purpose: To reference a line number in a transaction set.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

LX01 554 Assigned Number R 1/6 M N0 1/6

ELEMENT SUMMARY

LX01 Assigned Number

Number assigned for differentiation within a transaction set

Line Numbers in a transaction set, incremented by 1 for each service line.


October 31, 2007 163

IMPLEMENTATION

SV2 INSTITUTIONAL SERVICE LINE

Loop: 2400 – Service Line Number Usage: REQUIRED Repeat: 1

Note:

Example: SV2*300*HC: 80019*73.42*UN*1~ SV2*001*HC: 1*73.42*UN*01*0*0~

STANDARD

SV2 Institutional Service


Requirement: Optional Max Use: 1 Purpose: To specify the claim service detail for a Health Care institution Syntax: 01 R0102 – At least one of SV201 or SV202 is required.

04 P0405 – If either SV204 or SV205 is present, then the other is required. Semantic: 01 SV201 is the revenue code.

03 SV203 is a submitted charge amount. 07 SV207 is a non covered charge amount. 08 SV208 is the detail service line indicator. A “Y” value indicates a detail

service line; an “N” value indicates a summary service line. 03 C003-03 modifies the value in C003-02. 04 C003-04 modifies the value in C003-02. 05 C003-05 modifies the value in C003-02. 06 C003-06 modifies the value in C003-02. 07 C003-07 is the description of the procedure identified in C003-02.


October 31, 2007 164

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

SV201 234 Product/Service ID R 1/48 X/Z AN 1/48

SV202 C003 Composite Medical Procedure Identifier S X

SV202-01 235 Product/Service ID Qualifier R 2/2 M ID 2/2

SV202-02 234 Product/Service ID R 1/48 M AN 1/48

SV202-03 1339 Procedure Modifier S 2/2 O/Z AN 2/2




SV202-07 352 Description NU O/Z AN 1/80

SV203 782 Monetary Amount R 1/18 O/Z R 1/18

SV204 355 Unit or Basis for Measurement Code R 2/2 X ID 2/2

SV205 380 Quantity R 1/15 X R 1/15

SV206 1371 Unit Rate S 1/10 O R 1/10

SV207 782 Monetary Amount S 1/18 O/Z R 1/18

SV208 1073 Yes/No Condition or Response Code NU O/Z ID 1/1

SV209 1345 Nursing Home Residential Status Code NU O ID 1/1

SV210 1337 Level of Care Code NU O ID 1/1

ELEMENT SUMMARY

SV201 Revenue Code


For Medicare, Medicaid, and Non-Medicare Paper Form Equivalent: UB BOX #42 Do not key any line items for revenue code “001" - Total Charges.

For Non-Medicare, and Medicaid: Critical default value is “001. When critical default value is used, 2320 NTE01 is set to “CD Rev”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID

For Medicare and MSN defaults to value “001”

SV202 HCPCS/RATES

To identify a medical procedure by its standardized codes and applicable modifiers

For Non-Medicare and Medicaid: Required if present and legible on paper form Paper Form Equivalent: UB BOX #44.


October 31, 2007 165

SV202-01 Product/Service ID Qualifier

Code identifying the type/source of the descriptive number used in Product/Service ID (234) CODE DEFINITION HC Health Care Financing Administration Common Procedural Coding

System (HCPCS) Codes IV Home Infusion EDI Coalition (HIEC) Produce/Service Code N1 National Drug Code in 4-4-2 Format N2 National Drug Code in 5-3-2 Format N3 National Drug Code in 5-4-1 Format N4 National Drug Code in 5-4-2 Format ZZ Mutually Defined

Data Conversion Vendor will set the value to "HC".

SV202-02 Product/Service ID


Value must be set to “1” if unreadable

SV202-03 Procedure Modifier This identifies special circumstances related to the performance of the service, as defined by trading partners

HCPCS Modifier 1

SV202-04 Procedure Modifier

This identifies special circumstances related to the performance of the service, as defined by trading partners

HCPCS Modifier 2

SV202-05 Procedure Modifier This identifies special circumstances related to the performance of the service, as defined by trading partners

HCPCS Modifier 3

SV202-06 Procedure Modifier

This identifies special circumstances related to the performance of the service, as defined by trading partners

HCPCS Modifier 4

SV202-07 Description A free-form description to clarify the related data elements and their content

Not Used

SV203 Monetary Amount

Monetary amount

Paper Form Equivalent: UB BOX #47, or MSN form.

Use this amount to indicate the submitted charge amount

For Non-Medicare and Medicaid Critical default value is “0”. When critical default value is used, 2320 NTE01 is set to “CD AMT”, and 1000A NM109 - Submitter ID value is set to Other Submitter ID.

For MSN, and MSN dup: Replicate from 2300 CLM02 – TOTAL CHARGE.

For Medicare Defaults to value “0”


October 31, 2007 166

SV204 Unit or Basis for Measurement Code


CODE DEFINITION DA Days F2 International Unit UN Unit

Defaults to value “UN”

SV205 Quantity

Numeric Value of quantity



SV206 Unit Rate The rate per unit of associate revenue for hospital accommodation


This data element is required when the associated revenue code is 100-219


SV207 Non Covered Charges

Monetary amount

For Non Medicare and Medicaid: Required if present on paper form Paper Form Equivalent: UB BOX #48.

Defaults to value “0” if unreadable

SV208 Yes/No Condition or Response Code


Not Used

SV209 Nursing Home Residential Status Code Code specifying the status of a nursing home resident at the time of service

Not Used

SV210 Level of Care Code

Code specifying the level of care provided by a nursing home facility

Not Used


October 31, 2007 167

IMPLEMENTATION

DTP SERVICE LINE DATE

Loop: 2400 – Service Line Number Usage: REQUIRED Repeat: 1 Situational Rule: Required if necessary to meet specific Trading Partner data requirements.

Note: Replicate first date from Statement date segment of Claim loop 2300.

Example: DTP*472*D8*19960819~

STANDARD

DTP Date or Time or Period



DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes




ELEMENT SUMMARY



CODE DEFINITION 472 Service




DTP03 Date Time Period


For Non-Medicare and Medicaid, key from UB BOX #45 Default value and value for all other bill types is replicated value from first date of 2300 Statement Date segment.


October 31, 2007 168

IMPLEMENTATION

HCP LINE PRICING/REPRICING INFORMATION

Loop: 2400 – Service Line Number Usage: SITUATIONAL Repeat: 1 Notes: Data Conversion Vendor will not be populating this segment. This segment is required for PPO re-pricing. Example: HCP*03*100*10*RPO12345~

STANDARD

HCP Health Care Pricing


Requirement: Optional Max Use: 1 Purpose: To specify pricing or re-pricing information about a health care claim or line item Syntax: 01 R0113 – At least one of HCP01 or HCP13 is required.

09 P0910 – If either HCP09 or HCP10 is present, then the other is required. 11 P1112 – If either HCP11 or HCP12 is present, then the other is required.

Semantic: 02 HCP02 is the allowed amount. 03 HCP03 is the savings amount. 04 HCP04 is the re-pricing organization identification number. 05 HCP05 is the pricing rate associated with per diem or flat rate re-pricing. 06 HCP06 is the approved DRG code. 07 HCP07 is the approved DRG amount. 08 HCP08 is the approved revenue code. 10 HCP10 is the approved procedure code. 12 HCP12 is the approved service units or inpatient days. 13 HCP13 is the rejection message returned from the third party organization. 15 HCP15 is the exception reason generated by a third party organization.

Comments: 06 HCP06, HCP07, HCP08, HCP10 and HCP12 are fields that will contain different values from the original submitted values.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

HCP01 1473 Pricing Methodology R 2/2 X ID 2/2

HCP02 782 Monetary Amount R 1/18 O/Z R 1/18



HCP05 118 Rate NU O/Z R 1/9




October 31, 2007 169


HCP09 235 Product/Service ID Qualifier S 2/2 X ID 2/2


HCP11 355 Unit or Basis for Measurement Code S 2/2 X ID 2/2

HCP12 380 Quantity S 1/15 X/Z R 1/15

HCP13 901 Reject Reason Code S 2/2 X/Z ID 2/2

HCP14 1526 Policy Compliance Code S 1/2 O ID 1/2

HCP15 1527 Exception Code S 1/2 O/Z ID 1/2

ELEMENT SUMMARY

HCP01 Pricing Methodology

Code specifies the pricing methodology at which the claim or line item has been priced or re-priced.

CODE DEFINITION 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing


Monetary amount

This is the Allowed Amount

HCP03 Monetary Amount Monetary amount

This data element is required when it is necessary to report Savings Amount on claims, which has been priced or re-priced.



This data element is required when it is necessary to report Re-Pricing Organization’s ID on the claim, which has been priced or re-priced.


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HCP05 Rate

Rate expressed in the standard monetary denomination for the currency specified

Not Used

HCP06 Reference Identification Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier



Monetary amount


HCP08 Product/Service ID


This data element is required when it is necessary to report Approved Revenue Code on claims, which has been priced or Re-priced.

HCP09 Product/Service ID Qualifier

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

CODE DEFINITION HC Health Care Financing Administration Common Procedural Coding

System (HCPCS) Codes

Required when HCP10 exists.

HCP10 Product/Service ID Identifying number for a product or service

This data element is required when it is necessary to report Approved HCPCS Code on claims, which has been priced or Re-priced.

HCP11 Unit or Basis for Measurement Code


CODE DEFINITION DA Days UN Unit

HCP12 Quantity


This data element is required when it is necessary to report Approved Service Unit Count on claims, which has been priced or re-priced.


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HCP13 Reject Reason Code Code assigned by issuer to identify reason for rejection

CODE DEFINITION T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information For re-pricing

This data element is required when it is necessary to report Rejection Message on claims which has been priced or re-priced.

HCP14 Policy Compliance Code

Code specifying policy compliance

CODE DEFINITION 1 Procedure Followed (Compliance) 2 Not Followed – Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital

This data element is required when it is necessary to report Policy Compliance Code on claims, which has been priced or re-priced.

HCP15 Exception Code

Codes specifying the exception reason for consideration of out of network health care services.

CODE DEFINITION 1 Non-Network Institutional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other

This data element is required when it is necessary to report Exception Reason Code on claims, which have been priced or Re-priced.


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IMPLEMENTATION

SE TRANSACTION SET TRAILER

Loop: Usage: REQUIRED Repeat: 1 Example: SE*1230*0001~

STANDARD

SE Transaction Set Trailer

Level: Detail Position: 555 Loop:

Requirement: Mandatory Max Use: 1 Purpose: To indicate the end of the transaction set and provide the count of the transmitted segments

(including the beginning (ST) and ending (SE) segments) Comments: 00 SE is the last segment of each transaction set.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

SE01 96 Number of Included Segments R 1/10 M N0 1/10

SE02 329 Transaction Set Control Number R 4/9 M AN 4/9

ELEMENT SUMMARY

SE01 Number of Included segments

Total number of segments included in a transaction set including ST and SE segments

SE02 Transaction Set Control Number Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

SE02 must match ST02


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A X12 Nomenclature A.1 Interchange and Application Control Structures A.1.1 Interchange Control Structure

The transmission of data proceeds according to very strict format rules to ensure the integrity and maintain the efficiency of the interchange. Each business grouping of data is called a transaction set. For instance, a group of benefit enrollments sent from a sponsor to a payer is considered a transaction set. Each transaction set contains groups of logically related data in units called segments. For instance, the N4 segment used in the transaction set conveys the city, state, ZIP Code, and other geographic information. A transaction set contains multiple segments, so the addresses of the different parties, for example, can be conveyed from one computer to the other. An analogy would be that the transaction set is like a freight train; the segments are like the train's cars; and each segment can contain several data elements the same as a train car can hold multiple crates. The sequence of the elements within one segment is specified by the ASC X12 standards as well as the sequence of the segments in the transaction set. In a more conventional computing environment, the segments would be equivalent to records, and the elements equivalent to fields within the records. Similar transaction sets, called "functional groups," can be sent together within a transmission. Each functional group is prefaced by a group start segment; and a functional group is terminated by a group end segment. One or more functional groups are prefaced by an interchange header and followed by an interchange trailer. Figure A1, Transmission Control Schematic, on the next page, illustrates this interchange control. The interchange header and trailer segments envelop one or more functional groups or interchange-related control segments and perform the following functions:

1. Define the data element separators and the data segment terminator.

2. Identify the sender and the receiver.

3. Provide control information for the interchange.

4. Allow for authorization and security information.


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Communications Transport Protocol

ISA Interchange Group Header

GS Functional Group Header


Detail Segments For example, Benefit Enrollment

SE Transaction Set Trailer ST Transaction Set Header

Detail Segments For example, Benefit Enrollment


GE Functional Group Trailer



Detail Segments For example, Claim Payment



IEA Interchange Control Trailer

Communications Transport Protocol


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Figure A1. Transmission Control Schematic A.1.2 Application Control Structure Definitions and Concepts A.1.2.1 Basic Structure

A data element corresponds to a data field in data processing terminology. The data element is the smallest named item in the ASC X12 standard. A data segment corresponds to a record in data processing terminology. The data segment begins with a segment ID and contains related data elements. A control segment has the same structure as a data segment; the distinction is in the use. The data segment is used primarily to convey user information, but the control segment is used primarily to convey control information and to group data segments.

A.1.2.2 Basic Character Set

The section that follows is designed to have representation in the common character code schemes of EBCDIC, ASCII, and CCITT International Alphabet 5. The ASC X12 standards are graphic-character-oriented; therefore, common character encoding schemes other than those specified herein may be used as long as a common mapping is available. Because the graphic characters have an implied mapping across character code schemes, those bit patterns are not provided here. The basic character set of this standard, shown in Figure A2, Basic Character Set, includes those selected form the uppercase letters, digits, space, and special characters as specified below.

A..Z

0..9 !

"

&

'

(

)

*

+

,

-

.

/

:

;

?

=

(blank)

Figure A2. Basic Character Set

A.1.2.3 Extended Character Set

An extended character set may be used by negotiation between State Farm and the sending/receiving trading partner and includes the lowercase letters and other special characters as specified in Figure A3, Extended Character Set.

a..z

%

~

@ [

]

_

{

}

\

|

<

>

#

$

Figure A3. Extended Character Set Note that the extended characters include several character codes that have multiple graphical representations for a specific bit pattern. The complete list appears in other standards such as CCITT S.5. Use of the USA graphics for these codes presents no problem unless data is exchanged with an international partner. Other problems, such as the translation of item descriptions from English to French, arise when exchanging data with an international partner, but minimizing the use of codes with multiple graphics eliminates one of the more obvious problems.


October 31, 2007 176

A.1.2.4 Control Characters

Two control character groups are specified; they have only restricted usage. The common notation for these groups is also provided, together with the character coding in three common alphabets. In the Matrix A1, Base Control Set, the column IA5 represents CCITT V.3 International Alphabet 5.

A.1.2.5 Base Control Set

The base control set includes those characters that will not have a disruptive effect on most communication protocols. These are requested by:

NOTATION NAME EBCDIC ASCII IA5

BEL

bell 2F 07 07

HT

horizontal tab 05 09 09

LF line feed 25 0A 0A

VT vertical tab 0B 0B 0B

FF form feed 0C 0C 0C

CR carriage return 0D 0D 0D

FS file separator 1C 1C 1C

GS group separator 1D 1D 1D

RS record separator 1E 1E 1E

US unit separator 1F 1F 1F

NL new line 15

Matrix A1. Base Control Set

The group separator (GS) may be an exception in this set because it is used in the 3780 communications protocol to indicate blank space compression.

A.1.2.6 Extended Character Set

The extended control set includes those that may have an effect on a transmission system. These are shown in Matrix A2, Extended Control Set.

NOTATION NAME EBCDIC ASCII IA5

SOH start of header 01 01 01

STX

start of text 02 02 02

ETX end of text 03 03 03

EOT end of transmission 37 04 04

ENQ enquiry 2D 05 05

ACK acknowledge 2E 06 06

DC1 device control 1 11 11 11



DC4 device control 4 3C 14 14

NAK negative acknowledge 3D 15 15

SYN synchronous idle 32 16 16

ETB end of block 26 17 17

Matrix A2. EXTENDED Character Set


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A.1.2.7 Delimiters

A delimiter is a character used to separate two data elements (or subelements) or to terminate a segment. The delimiters are an integral part of the data. Delimiters are specified in the interchange header segment, ISA. The ISA segment is a 105 byte fixed length record. The data element separator is byte number 4; the component element separator is byte number 105; and the segment terminator is the byte that immediately follows the component element separator. Once specified in the interchange header, the delimiters are not to be used in a date element value elsewhere in the interchange. For consistency, this implementation guide uses the delimiters shown in Matrix A3, Delimiters, in all examples of EDI transmissions.

CHARACTER

NAME DELIMITER

* Asterisk Data Element Separator

:

Colon Subelement Separator

~ Tilde Segment Terminator

Matrix A3. Delimiters

The delimiters above are for illustrative purposes only and are not specific recommendations or requirements. Users of this implementation guide should be aware that an application system may use some valid delimiter characters within the application data. Occurrences of delimiter characters in transmitted data within a data element can result in errors in translation programs. The existence of asterisks (*) within transmitted application data is a known issue that can affect translation software.

A.1.3 Business Transaction Structure Definitions and Concepts

The ASC X12 standards define commonly used business transactions (such as a health care claim) in a formal structure called "transaction sets." A transaction set is composed of a transaction set header control segment, one or more data segments, and a transaction set trailer control segment. Each segment is composed of the following: • A unique segment ID • One or more logically related data elements each preceded by a data element separator • A segment terminator

A.1.3.1 Data Element

The data element is the smallest named unit of information in the ASC X12 standard. Data elements are identified as either simple or component. A data element that occurs as an ordinally positioned member of a composite data structure is identified as a component data element. A data element that occurs in a segment outside of the defined boundaries of a composite data structure is identified as a simple data element. The distinction between simple and component data elements is strictly a matter of context because a data element can be used in either capacity. Data elements are assigned a unique reference number. Each data element has a same, description, type, minimum length, and maximum length. For ID type data elements, this guide provides the applicable ASC X12 code values and their descriptions or references where the valid code list can be obtained. Each data element is assigned a minimum and a maximum length. The length of the data element value is the number of character positions used except as noted for numeric, decimal, and binary elements.


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The data element types shown in Matrix A4, Data Element Types, appear in this implementation guide.

SYMBOL

TYPE

Nn Numeric

R

Decimal

ID Identifier

AN String

DT Date

TM Time

B Binary

Matrix A4. Data Element Types A.1.3.1.1 Numeric

A numeric data element is represented by one or more digits with an optional leading sign representing a value in the normal base 10. The value of a numeric data element includes an implied decimal point. It is used when the position of the decimal point within the data is permanently fixed and is not to be transmitted with the data This guide denotes the number of implied decimal positions. The representation for this data element type is "Nn" where N indicates that it is numeric and n indicates the number of decimal positions to the right of the implied decimal point. If n is 0, it need not appear in the specification; N is equivalent to N0. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus sign (+) should not be transmitted.

EXAMPLE A transmitted value of 1234, when specified as numeric type N2, represents a value of 12.34.

Leading zeros should be suppressed unless necessary to satisfy a minimum length requirement. The length of a numeric type data element does not include the optional sign.

A.1.3.1.2 Decimal

A decimal data element may contain an explicit decimal point and is used for numeric values that have a varying number of decimal positions. This data element type is represented as "R". The decimal point always appears in the character stream if the decimal point is at any place other than the right end. If the value is an integer (decimal point at the right end) the decimal point should be omitted. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus sign (+) should not be transmitted. Leading zeros should be suppressed unless necessary to satisfy a minimum length requirement. Trailing zeros following the decimal point should be suppressed unless necessary to indicate precision. The use of triad separators (for example, the commas in 1,000,000) is expressly prohibited. The length of a decimal type data element does not include the leading sign or a decimal point.

EXAMPLE A transmitted value of 12.34 represents a decimal value of 12.34.


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A.1.3.1.3 Identifier

An identifier data element always contains a value from a predefined list of codes that is maintained by the ASC X12 Committee or some other body recognized by the Committee. Trailing spaces should be suppressed unless they are necessary to satisfy a minimum length. An identifier is always left justified. The representation for this data element type is "ID".

A.1.3.1.4 String

A string data element is a sequence of any characters from the basic or extended character sets. The significant characters shall be left justified. Leading spaces, when they occur are presumed to be significant characters. Trailing spaces should be suppressed unless they are necessary to satisfy a minimum length. The representation of this data element type is "AN".

A.1.3.1.5 Date

A date data element is used to express the standard date in YYMMDD or CCYYMMDD format in which CC is the first two digits of the calendar year, YY is the last two digits of the calendar year, MM is the month (01 to 12), and DD is the day in the month (01 to 31).

A.1.3.1.6 Time

A time data element is used to express the ISO standard time HHMMSSd..d format in which HH is the hour for a 24 hour clock (00 to 23), MM is the minute (00 to 59), SS is the second (00 to 59) and d..d is decimal seconds. The representation for this data element type is "TM". The length of the data element determines the format of the transmitted time.

A.1.3.2 Composite Data Structure

The composite data structure is an intermediate unit of information in a segment. Composite data structures are composed of one or more logically related simple data elements, each, except the last, followed by a sub-element separator. The final data element is followed by the next data element separator or the segment terminator. Each simple data element within a composite is called a component. Each composite data structure has a unique four-character identifier, a name, and a purpose. The identifier serves as a label for the composite. A composite data structure can be further defined through the used of syntax notes, semantic notes, and comments. Each component within the composite is further characterized by a reference designator and a condition designator. The reference designators and the condition designators are described below.

A.1.3.3 Data Segment The data segment is an intermediate unit of information in a transaction set. In the data stream, a data segment consists of a segment identifier, one or more composite data structures or simple data elements preceded by a data element separator and succeeded by a segment terminator. Each data segment has a unique two- or three-character identifier, a name, and a purpose. The identifier serves as a label for the data segment. A segment can be further defined through the use of syntax notes, semantic notes, and comments. Each simple data element or composite data structure within the segment is further characterized by a reference designator and a condition designator.

A.1.3.4 Syntax Notes

Syntax notes describe relational conditions among two or more data segment units within the same segment, or among two or more component data elements within the same composite data structure. For a complete description of the relational conditions, see A.1.3.8, Condition Designator.


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A.1.3.5 Semantic Notes

Simple data elements or composite data structures may be referenced by a semantic note within a particular segment. A semantic note provides important additional information regarding the intended meaning of a designated data element, particularly a generic type, in the context of its use within a specified data segment. Semantic notes may also define a relational condition among data elements in a segment based on the presence of a specific value (or one of a set of values) in one of the data elements.

A.1.3.6 Comments

A segment comment provides additional information regarding the intended use of the segment. A.1.3.7 Reference Designator

Each simple data element or composite data structure in a segment is provided a structured code that indicates the segment in which it is used and the sequential position within the segment. The code is composed of the segment identifier followed by a two-digit number that defines the position of the simple data element or composite data structure in that segment. For purposes of creating reference designators, the composite data structure is viewed as the hierarchical equal of the simple data element. Each component data element in a composite data structure is identified by a suffix appended to the reference designator for the composite data structure of which it is a member. This suffix is a two-digit number, prefixed with a hyphen that defines the position of the component data element in the composite data structure.

EXAMPLE • The first simple element of the CLP segment would be identified as CLP01. • The first position in the SVC segment is occupied by a composite data structure that contains

seven component data elements, the reference designator for the second component data element would be SVC01-02.


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A.1.3.8 Condition Designator

Data element conditions are of three types: mandatory, optional, and relational. They define the circumstances under which a data element may be required to be present or not present in a particular segment.

DESIGNATOR DESCRIPTION M- Mandatory The designation of mandatory is absolute in the sense that there is no dependency on other

data elements. This designation may apply to either simple data elements or composite data structures. If the designation applies to a composite data structure, then at least one value of a component data element in that composite data structure shall be included in the data segment.

O- Optional The designation of optional means that there is no requirement for a simple data element or

composite data structure to be present in the segment. The presence of a value for a simple data element or the presence of value for any of the component data elements of a composite data structure is at the option of the sender.

X- Relational Relational conditions may exist among two or more simple data elements within the same data

segment based on the presence or absence of one of those data elements (presence means a data element must not be empty). Relational conditions are specified by a condition code (see table below) and the reference designators of the affected data elements. A data element may be subject to more than one relational condition.

CONDITION CODE DEFINITION P- Paired or If any element specified in the relational Multiple condition is present, then all of the elements specified must be present. ___________________________________________________________________ R- Required At least one of the elements specified in the condition must be

present. E- Exclusion Not more than one of the elements specified in the condition may be

present. C- Conditional If the first element specified in the condition is present, then all of the

other elements must be present. However, any or all of the elements not specified as the first element in the condition may appear without requiring that the first element be present. The order of the elements in the condition does not have to be the same as the order of the data elements in the data segment.

L- List If the first element specified in the condition is Conditional present, then at least one of the remaining elements must be present.

However, any or all of the elements not specified as the first element in the condition may appear without requiring that the first element be present. The order of the elements in the condition does not have to be the same as the order of the data elements in the data segment.

Table A5. Condition Designator


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A.1.3.9 Absence of Data

Any simple data element that is indicated as mandatory must not be empty if the segment is used. At least one component data element of a composite data structure that is indicated as mandatory must not be empty if the segment is used. Optional simple data elements and/or composite data structures and their preceding data element separators that are not needed should be omitted if they occur at the end of a segment. If they do not occur at the end of the segment, the simple data element values and/or composite data structure values may be omitted. Their absence is indicated by the occurrence of their preceding data element separators, in order to maintain the element's or structure's position as defined in the data segment.

Likewise, when additional information is not necessary within a composite, the composite may be terminated by providing the appropriate data element separator or segment terminator.

A.1.3.10 Control Segments

A control segment has the same structure as a data segment, but it is used for transferring control information rather than application information.

A.1.3.10.1 Loop Control Segments

Loop control segments are used only to delineate bounded loops. Delineation of the loop shall consist of the loop header (LS segment) and the loop trailer (LE segment). The loop header defines the start of a structure that must contain one or more iterations of a loop of the data segments and provides the loop identifier for this loop. The loop trailer defines the end of the structure. The LS segment appears only before the first occurrence of the loop, and the LE segment appears only after the last occurrence of the loop. Unbounded looping structures do not use loop control segments.

A.1.3.10.2 Transaction Set Control Segments

The transaction set is delineated by the transaction set header (ST segment) and the transaction set trailer (SE segment). The transaction set header identifies the start and identifier of the transaction set. The transaction set trailer identifies the end of the transaction set and provides a count of the data segments, which includes the ST and SE segments.

A.1.3.10.3 Functional Group Control Segments

The functional group is delineated by the functional group header (GS segment) and the functional group trailer (GE segment). The functional group header starts and identifies one or more related transaction sets and provides a control number and application identification information. The functional group trailer defines the end of the functional group of related transaction sets and provides a count of contained transaction sets.


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A.1.3.10.4 Relations among Control Segments

The control segment of this standard must have a nested relationship as is shown and annotated in this subsection. The letters preceding the control segment name are the segment identifier for that control segment. The indentation of segment identifiers shown below indicates the subordination among control segments.

GS Functional Group Header, starts a group of related transaction sets.

ST Transaction Set Header, starts a transaction set.

LS Loop Header, starts a bounded loop of data segments but is not part of the loop.

LS Loop Header, starts an inner, nested, bounded loop.

LE Loop Trailer, ends an inner, nested, bounded loop.

LE Loop Trailer, ends a bounded loop of data segments but is not part of the loop.

SE Transaction Set Trailer, ends a transaction set. GE Functional Group Trailer, ends a group of related transaction sets.

More than one ST/SE pair, each representing a transaction set, may be used within one functional group. Also, more than one LS/LE pair, each representing a bounded loop, may be used within one transaction set.

A.1.3.11 Transaction Set

The transaction set is the smallest meaningful set of information exchanged between trading partners. The transaction set consists of a transaction set header segment, one or more data segments in a specified order, and a transaction set trailer segment. See Figure A1, Transmission Control Schematic.

A.1.3.11.1 Transaction Set Header and Trailer

A transaction set identifier uniquely identifies a transaction set. This identifier is the first data element of the Transaction Set Header Segment (ST). A user assigned transaction set control number in the header must match the control number in the Trailer Segment (SE) for any given transaction set. The value for the number of included segments in the SE segment is the total number of segments in the transaction set, including the ST and SE segments.

A.1.3.11.2 Data Segment Groups

The data segments in a transaction set may be repeated as individual data segments or as unbounded or bounded loops.

A.1.3.11.3 Repeated Occurrences of Single Data Segments

When a single data segment is allowed to be repeated, it may have a specified maximum number of occurrences defined at each specified position within a given transaction set standard. Alternatively, a segment may be allowed to repeat an unlimited number of times. The notation for an unlimited number of repetitions is ">1".

A.1.3.11.4 Loops of Data Segments

Loops are groups of semantically related segments. Data segment loop may be unbounded or bounded.


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A.1.3.11.4.1 Unbounded Loops

To establish the iteration of a loop, the first data segment in the loop must appear once and only once in each iteration. Loops may have a specified maximum number of repetitions. Alternatively, the loop may be specified as having an unlimited number of iterations. The notation for an unlimited number of repetitions is ">1".

A specified sequence of segments is in the loop. Loops themselves are optional or mandatory. The requirement designator of the beginning segment of a loop indicates whether at least one occurrence of the loop is required. Each appearance of the beginning segment defines an occurrence of the loop.

The requirement designator of any segment within the loop after the beginning segment applies to that segment for each occurrence of the loop. If there is a mandatory requirement designator for any data segment within the loop after the beginning segment, that data segment is mandatory for each occurrence of the loop. If the loop is optional, the mandatory segment only occurs if the loop occurs.

A.1.3.11.4.2 Bounded Loops

The characteristics of unbounded loops described previously also apply to bounded loops. In addition, bounded loops require a Loop Start Segment (LS) to appear before the first occurrence and a Loop and Segment (LE) to appear after the last occurrence of the loop. If the loop does not occur, the LS and LE segments are suppressed.

A.1.3.11.5 Data Segments in a Transaction Set

When data segments are combined to form a transaction set, three characteristics are applied to each data segment: a requirement designator, a position in the transaction set, and a maximum occurrence.

A.1.3.11.6 Data Segment Requirement Designators

A data segment, or loop, has one of the following requirement designators for insurance transaction sets, indicating its appearance in the data stream of a transmission. These requirement designators are represented by a single character code.

DESIGNATOR DESCRIPTION M- Mandatory This data segment must be included in the transaction set. (Note that a data segment may be

mandatory in a loop of data segments, but the loop itself is optional if the beginning segment of the loop is designated as optional).

O- Optional The presence of this data segment is the optional of the sending party.

A.1.3.11.7 Data Segment Position

The ordinal positions of the segments in a transaction set are explicitly specified for that transaction. Subject to the flexibility provided by the optional requirement designators of the segments, this positioning must be maintained.

A.1.3.11.8 Data Segment Occurrence

A data segment may have a maximum occurrence of one, a finite number greater than one, or an unlimited number indicated by ">1".

A.1.3.12 Functional Group

A functional group is a group of similar transaction sets that is bounded by a functional group header segment and a functional group trailer segment. The functional identifier defines the group of transactions that may be included within the functional group. The value for the functional group control number in the header and trailer control segments must be identical for any given group. The value for the number of included transaction sets is the total number of transaction sets in the group. See Figure A1, Transmission Control Schematic.


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A.1.4 Envelopes and Control Structures

A.1.4.1 Interchange Control Structures

Typically, the term "interchange" denotes the ISA/IEA envelope that is transmitted between trading/business partners. Interchange control is achieved through several "control" components. The interchange control number is contained in data element ISA13 of the ISA segment. The identical control number must also occur in data element 02 of the IEA segment. Most commercial translation software products will verify that these two fields are identical. In most translation software products, if these fields are different the interchange will be "suspended" in error.

There are many other features of the ISA segment that are used for control measures. For instance, the ISA segment contains data elements such as authorization information, security information, sender identification, and receiver identification that can be used for control purposes. These data elements are agreed upon by the trading partners prior to transmission and are contained in the written trading partner agreement. The interchange date and time data elements as well as the interchange control number within the ISA segment are used for debugging purposes when there is a problem with the transmission or the interchange.

Data Element ISA12. Interchange Control Version Number, indicates the version of the ISA/IEA envelope. The ISA12 does not indicate the version of the transaction set that is being transmitted but rather the envelope that encapsulates the transaction. An Interchange Acknowledgment can be denoted through data element ISA14. The acknowledgment that would be sent in reply to a "yes" condition in data element ISA14 would be TA1 segment. Data Element ISA15, Test Indicator, is used between trading partners to indicate that the transmission is in a "test" or "production" mode. This becomes significant when the production phase of the project is to commence. Data element ISA16, Sub-element Separator, is used by the translator for interpretation of composite data elements.

The ending component of the interchange or ISA/IEA envelope is the IEA segment. Data element IEA01 indicates the number of functional groups that are included within the interchange. In most commercial translation software products, an aggregate count of functional groups is kept while interpreting the interchange. This count is then verified with data element IEA01. If there is a discrepancy, in most commercial products, the interchange is suspended. The other data element in the IEA segment is IEA02 which is referenced above.

See Appendix B, EDI Control Directory, for a complete detailing of the interchange control header and trailer.

A.1.4.2 Functional Groups

Control structures within the functional group envelope include the functional identifier code in GS01. The Functional Identifier Code is used by the commercial translation software during interpretation of the interchange to determine the different transaction sets that may be included within the functional group. If an inappropriate transaction set is contained within the functional group, most commercial translation software will suspend the functional group within the interchange. The Application Sender's Code in GS02 can be used to identify the sending unit of the transmission. The Application Receiver's Code in GS03 can be used to identify the receiving unit of the transmission. The functional group contains a creation date (GS04) and creation time (GS05) for the functional group. The Group Control Number is contained in GS06. These data elements (GS04, GS05, and GS06) can be used for debugging purposes during problem resolution. GS08, Version/Release/Industry Identifier Code is the version/release/sub-release of the transaction sets being transmitted in this functional group. Appendix B provides guidance for the value for this data element. The GS08 does not represent the version of the interchange (ISA/IEA) envelope but rather the version/release/sub-release of the transaction sets that are encompassed within the GS/GE envelope.

The Functional Group Control Number in GS06 must be identical to data element 02 of the GE segment. Data element GE01 indicates the number of transaction sets within the functional group. In most commercial translation software products, an aggregate count of the transaction sets is kept while interpreting the functional group. This count is then verified with data element GE01.

See Appendix B, EDI Control Directory, for a complete detailing of the functional group header and trailer.


October 31, 2007 186

A.1.5 Acknowledgments

A.1.5.1 Interchange Acknowledgment, TA1

The Interchange or TA1 Acknowledgment is a means of replying to an interchange or transmission that has been sent. The TA1 verifies the envelopes only. Transaction set-specific verification is accomplished through use of the Functional Acknowledgment Transaction Set, 997. See A.1.5.2, Functional Acknowledgment, 997, for more details. The TA1 is a single segment and is unique in the sense that this single segment is transmitted without the GS/GE envelope structures. A TA1 can be included in an interchange with other functional groups and transactions.

Encompassed in the TA1 are the interchange control number, interchange date and time, interchange acknowledgment code, and the interchange note code. The interchange control number, interchange date and time are identical to those that were present in the transmitted interchange from the sending partner. This provides the capability to associate the TA1 with the transmitted interchange. TA104, Interchange Acknowledgment Code, indicates the status of the interchange control structure. This data element stipulates whether the transmitted interchange was accepted with no errors, accepted with errors, or rejected because of errors. TA105, Interchange Note Code, is a numeric code that indicates the error found while processing the interchange control structure. Values for this data element indicate whether the error occurred at the interchange or functional group envelope. The TA1 segment provides the capability for the receiving trading partner to notify the sending trading partner of problems that were encountered in the interchange control structure.

Due to the uniqueness of the TA1, implementation should be predicated upon the ability for the sending and receiving trading partners commercial translators to accommodate the uniqueness of the TA1.

See Appendix B, EDI Control Directory, for a complete detailing of the TA1 segment.

A.1.5.2 Functional Acknowledgment, 997

The Functional Acknowledgment Transaction Set, 997, has been designed to allow Trading partners to establish a comprehensive control function as a part of their business exchange process. This acknowledgment process facilitates control of EDI. There is a one-to-one correspondence between a 997 and a functional group. Segments within the 997 can identify the acceptance or rejection of the functional group. Segments within the 997 can identify the acceptance or rejection of the functional group, transaction sets or segments. Data elements in error can also be identified. There are many EDI implementations that have incorporated the acknowledgment process in all of their electronic communications. Typically, the 997 is used as a functional acknowledgment to a previously transmitted functional group. Many commercially available translators can automatically generate this transaction set through internal parameter settings. Additionally, translators will automatically reconcile received acknowledgments to functional groups that have been sent. The benefit to this process is that the sending trading partner can determine if the receiving trading partner has received ASC X12 transaction sets through reports that can be generated by the translation software to identify transmissions that have not been acknowledged. As stated previously, the 997 is a transaction set and thus is encapsulated within the interchange control structure (envelopes) for transmission. As with any information flow, an acknowledgment process is essential. If an "automatic" acknowledgment process is desired between trading partners then it is recommended that the 997 be used. See Appendix B, EDI Control Directory, for a complete detailing of transaction set 997.


October 31, 2007 187

B EDI Control Directory

B.1 Control Segments

• ISA Interchange Control Header Segment

• IEA

Interchange Control Trailer Segment • GS

Functional Group Header Segment • GE

Functional Group Trailer Segment • TA1

Interchange Acknowledgment Segment


October 31, 2007 188

IMPLEMENTATION

ISA INTERCHANGE CONTROL HEADER

Notes: 1. The ISA is a fixed record length segment and all positions within each of the data elements must be filled. The first element separator defines the element separator to be used through the entire interchange. The segment terminator used after the ISA defines the segment terminator to be used throughout the entire interchange. Spaces in the example are represented by"." for clarity.

Example: ISA*00*..........*01*SECRET....*ZZ*SUBMITTERS.ID...*ZZ

*RECEIVERS.ID...*980727*1250*U*00401*000000905*1*T*:~

STANDARD

ISA Interchange Control Header

Purpose:To start and identify an interchange of zero or more functional groups and interchange-related

control segments.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12

Attributes ISA01

I01

Authorization Information Qualifier

R 2/2

M ID 2/2

ISA02

I02

Authorization Information

R 10/10

M AN 10/10

ISA03

I03

Security Information Qualifier

R 2/2

M ID 2/2

ISA04

I04

Security Information

R 10/10

M AN 10/10

ISA05

I05

Interchange ID Qualifier

R 2/2

M ID 2/2

ISA06

I06

Interchange Sender ID

R 15/15

M AN 15/15

ISA07

I05

Interchange ID Qualifier

R 2/2

M ID 2/2

ISA08

I07

Interchange Receiver ID

R 15/15

M AN 15/15

ISA09

I08

Interchange Date

R 6/6

M DT 6/6

ISA10

I09

Interchange Time

R 4/4

M TM 4/4

ISA11

I10

Interchange Control Standards Identifier

R 1/1

M ID 1/1

ISA12

I11

Interchange Control Version Number

R 5/5

M ID 5/5

ISA13

I12

Interchange Control Number

R 9/9

M N0 9/9

ISA14

I13

Acknowledgment Requested

R 1/1

M ID 1/1

ISA15

I14

Test Indicator

R 1/1

M ID 1/1

ISA16

I15

Component Element Separator

R 1/1

M AN 1/1


October 31, 2007 189

ELEMENT SUMMARY

ISA01 Authorization Information Qualifier

Code to identify the type of information in the Authorization Information.

CODE DEFINITION 00 No Authorization Information Present (No Meaningful Information in I02) 03 Additional Data Identification

ISA02 Authorization Information

Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01).

ISA03 Security Information Qualifier

Code to identify the type of information in the Security Information.

CODE DEFINITION 00 No Security Information Present (No Meaningful Information in ISA04) 01 Password

ISA04 Security Information

This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)

ISA05 Interchange ID Qualifier

Qualifier to designate the system/method of code structure used to designate the sender or receiver ID element being qualified

This ID qualifies the sender in ISA06.

CODE DEFINITION 01 Duns (Dun & Bradstreet) 12 Phone (Telephone Companies) NOT ADVISED 14 Duns Plus Suffix 30 U.S. Federal Tax Identification Number 33 National Association of Insurance Commissioners Company Code (NAIC) ZZ Mutually Defined

ISA06 Interchange Sender ID

Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element

ISA07 Interchange ID Qualifier

Qualifier to designate the system/method of code structure used to designate the sender or receiver ID element being qualified

This ID qualifies the receiver in ISA08.

CODE DEFINITION 01 Duns (Dun & Bradstreet) 12 Phone (Telephone Companies) NOT ADVISED 14 Duns Plus Suffix 30 U.S. Federal Tax Identification Number 33 National Association of Insurance Commissioners Company Code (NAIC) ZZ Mutually Defined


October 31, 2007 190

ISA08 Interchange Receiver ID

Identification code published by the receiver of the data. When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them

ISA09 Interchange Date

Date of the interchange

The date format is YYMMDD

ISA10 Interchange Time Time of the interchange.

The time format is HHMM.

ISA11 Interchange Control Standards Identifier

Code to identify the agency responsible for the control standard used by the message that is enclosed by the interchange header and trailer.

CODE DEFINITION U U.S. EDI Community of ASC X12, TDCC, and UCS

ISA12 Interchange Control Version Number

This version number covers the interchange control segments.

CODE DEFINITION 00401 Draft Standards for Trial Use Approved for Publication by ASC X12 Procedures Review Board through October 1997

ISA13 Interchange Control Number

A control number assigned by the interchange sender.

ISA14 Acknowledgment Code Code sent by the sender to request an interchange acknowledgment (TA1)

See Section A.1.5.1 for Interchange Acknowledgment Information.

CODE DEFINITION 0 No Acknowledgment Requested 1 Interchange Acknowledgment Requested

ISA15 Test Indicator

Code to indicate whether data enclosed by this interchange envelope is test or production.

CODE DEFINITION P Production Data T Test Data

ISA16 Component Element Separator

This field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator.


October 31, 2007 191

IMPLEMENTATION

IEA INTERCHANGE CONTROL TRAILER

Example: IEA*1*000000905~

STANDARD

IEA Interchange Control Trailer

Purpose: To define the end of an interchange of zero or more functional groups and interchange-

related control segments.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12

Attributes IEA01

I16

Number of Included Functional Groups

R 1/5

M N0 1/5

IEA02

I12


R 9/9

M N0 9/9

ELEMENT SUMMARY

IEA01 Number of Included Functional Groups

A count of the number of functional groups included in an interchange

IEA02 Interchange Control Number A control number assigned by the interchange sender


October 31, 2007 192

IMPLEMENTATION

GS FUNCTIONAL GROUP HEADER Example: GS*FR*SENDER CODE*RECEIVER CODE*19940331*0900*1*X*004010~

STANDARD


Purpose: To indicate the beginning of a functional group and to provide control information. Semantic: 04 GS04 is the Group Date 05 GS05 is the Group Time 06 The data interchange control number GS06 in this header must be identical to the

same data element in the associated Functional Group Trailer GE02. Comments: 00 A functional group of related transaction sets, within the scope of X12 standards,

consists of a collection of similar transaction sets enclosed by a functional group header and a functional group trailer.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

GS01

479

Functional Identifier Code

R 2/2

M ID 2/2

GS02

142

Application Sender's Code

R 2/15

M AN 2/15

GS03

124

Application Receiver's Code

R 2/15

M AN 2/15

GS04

373

Date

R 8/8

M DT 8/8

GS05

337

Time

R 4/8

M TM 4/8

GS06

28

Group Control Number

R 1/9

M N0 1/9

GS07

455

Responsible Agency Code

R 1/2

M ID 1/2

GS08

480

Version/Release/Industry Identifier Code

R 1/12

M AN 1/12


October 31, 2007 193

ELEMENT SUMMARY

GS01 Functional Identifier Code

Code identifying a group of application related Transaction Sets.

CODE DEFINITION FR Financial Information Reporting (821)

GS02 Application Sender's Code

Code identifying party sending transmission. Codes agreed to by trading partners

The identification code for the unit, sending the information.

GS03 Application Receiver's Code Code identifying party receiving transmission. Codes agreed to by trading partners.

The identification code for the unit, receiving the information.

GS04 Date

Date (CCYYMMDD)

This is the functional group creation date.

GS05 Time Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or

HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

GS06 Group Control Number

Assigned number originated and maintained by the sender.

GS07 Responsible Agency Code Code used in conjunction with Data Element 480 to identify the issuer of the standard.

CODE DEFINITION X Accredited Standards Committee X12

GS08 Version / Release / Industry Identifier Code

Code indicating the version, release, sub-release, and industry identifier of the EDI standard being used, including the GS and GE segments. If code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and sub-release, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user). If code in DE455 in GS segment is T, then other formats are allowed.

CODE DEFINITION 4010 Draft Standards Approved for Publication by ASC X12, Procedures Review Board through October 1997.


October 31, 2007 194

IMPLEMENTATION

GE FUNCTIONAL GROUP TRAILER

Example: GE*1*1~

STANDARD


Purpose: To indicate the end of a functional group and to provide control information. Semantic: 02 The data interchange control number GE02 in this trailer must be identical to the

same data element in the associated Functional Header GS06. Comments: 00 The use of identical data interchange control numbers in the associated functional group

header and trailer is designed to maximize functional group integrity. The control number is the same as that used in the corresponding header.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12

Attributes GE01

97

Number of Transaction Sets Included

R 1/6 M N0 1/6

GE02

28


R 1/9 M N0 1/9

ELEMENT SUMMARY

GE01 Number of Transaction Sets Included

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element.

GE02 Group Control Number



October 31, 2007 195

IMPLEMENTATION

TA1 INTERCHANGE ACKNOWLEDGMENT

Notes: 1. See section A.1.5.1 for Interchange Acknowledgment Information. 2. All fields must contain data. 3. This segment acknowledges the reception of an X12 interchange header and trailer from

a previous interchange. If the header/trailer pair was received correctly the TA1 will reflect a valid interchange, regardless of the validity of the contents of the data included inside the header/trailer envelope.

Example: TA1*000000905*980721*0930*A*001~

STANDARD

TA1 Interchange Acknowledgment

Purpose: To report the status of processing a received interchange header and trailer or the non-

delivery by a network provider.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

TA101

I12


R 9/9

M N0 9/9

TA102

I08

Interchange Date

R 6/6

M DT 6/6

TA103

I09

Interchange Time

R 4/4

M TM 4/4

TA104

I17

Interchange Acknowledgment Code

R 1/1

M ID 1/1

TA105

I18

Interchange Note Code

R 3/3

M ID 3/3

ELEMENT SUMMARY

TA101 Interchange Control Number

A control number assigned by the interchange sender

This number uniquely identifies the interchange data to the sender. It is assigned by the sender. Together with the sender ID it uniquely identifies the interchange data to the receiver. It is suggested that the sender, receiver, and all third parties be able to maintain an audit trail of interchanges using this number.

In the TA1, this should be the Interchange Control Number of the original interchange that this TA1 is acknowledging.

TA102 Interchange Date

Date of the interchange.

This is the date of the original interchange being acknowledged. (YYMMDD)


October 31, 2007 196

TA103 Interchange Time

Time of the interchange

This is the time of the original interchange being acknowledged. (HHMM)

TA104 Interchange Acknowledgment Code This indicates the status of the receipt of the interchange control structure.

CODE DEFINITION A The Transmitted Interchange Control Structure Header and Trailer Have Been received and Have No Errors. E The Transmitted Interchange Control Structure Header and Trailer Have

Been Received and Are Accepted But Errors Are Noted. This Means the Sender Must Not Resend This Data.

R The Transmitted Interchange Control Structure Header and Trailer are Rejected Because of Errors.

TA105 Interchange Note Code

This numeric code indicates the error found processing the interchange control structure.

CODE DEFINITION 000 No error 001 The Interchange Control Number in the Header and Trailer Do Not Match. The Value From the Header is Used in the Acknowledgment. 002 This Standard as Noted in the Control Standards Identifier is Not

Supported.

003 This Version of the Controls is Not Supported

004 The Segment Terminator is Invalid

005 Invalid Interchange ID Qualifier for Sender

006 Invalid Interchange Sender ID

007 Invalid Interchange ID Qualifier for Receiver

008 Invalid Interchange Receiver ID

009 Unknown Interchange Receiver ID

010 Invalid Authorization Information Qualifier Value

011 Invalid Authorization Information Value

012 Invalid Security Information Qualifier Value

013 Invalid Security Information Value

014 Invalid Interchange Date Value

015 Invalid Interchange Time Value 016 Invalid Interchange Standards Identifier Value

017 Invalid Interchange Version ID Value

018 Invalid Interchange Control Number Value

019 Invalid Acknowledgment Requested Value

020 Invalid Test Indicator Value

021 Invalid Number of Included Groups Value

022 Invalid Control Structure

023 Improper (Premature) End-of-File (Transmission)

024 Invalid Interchange Content (e.g., Invalid GS Segment)


October 31, 2007 197

025 Duplicate Interchange Control Number

026 Invalid Data Element Separator

027 Invalid Component Element Separator

028 Invalid Delivery Date in Deferred Delivery Request

029 Invalid Delivery Time in Deferred Delivery Request

030 Invalid Delivery Time Code in Deferred Delivery Request

031 Invalid Grade of Service Code


October 31, 2007 198

B.2 Functional Acknowledgment Transaction Set, 997

STANDARD

997 Functional Acknowledgment Functional Group ID: FA

This Draft Standard for Trial Use contains the format and establishes the data contents of the Functional Acknowledgment Transaction Set (997) for use within the context of an Electronic Data Interchange (EDI) environment. The transaction set can be used to define the control structures for a set of acknowledgments to indicate the results of the syntactical analysis of the electronically encoded documents. The encoded documents are the transaction sets, which are grouped in functional groups, used in defining transactions for business data interchange. This standard does not cover the semantic meaning of the information encoded in the transaction sets.

Header

POS. #

SEG.ID

NAME

REQ.DES.

MAX USE

LOOP REPEAT

010

ST


M

1

020

AK1

Functional Group Response Header

M

1

LOOP ID - AK2

999999

030

AK2

Transaction Set Response Header

O

1

LOOP ID - AK2/AK3

999999

040

AK3

Data Segment Note

O

1

050

AK4

Data Element Note

O

99

060

AK5

Transaction Set Response Trailer

M

1

070

AK9

Functional Group Response Trailer

M

1

080

SE

Transaction Set Trailer

M

1

NOTES:

1/010 These acknowledgments shall not be acknowledged, thereby preventing an endless cycle of acknowledgments of acknowledgments.

1/010 The Functional Group Header Segment (GS) is used to start the envelope for the Functional Acknowledgment Transaction Sets. In preparing the functional group of acknowledgments, the application sender's code and the application receiver's code, taken from the functional group being acknowledged, are exchanged; therefore, one acknowledgment functional group responds to only those functional groups from one application receiver's code to one applications sender's code.


October 31, 2007 199

1/010 There is only one Functional Acknowledgment Transaction Set per acknowledged functional group. 1/020 AK1 is used to respond to the functional group header and to start the acknowledgment for a functional group.

There shall be one AK1 segment for the functional group that is being acknowledged. 1/030 AK2 is used to start the acknowledgment of a transaction set within the received functional group. The AK2

segments shall appear in the same order as the transaction sets in the functional group that has been received and is being acknowledged.

1/040 The data segments of this standard are used to report the results of the syntactical analysis of the functional groups of transaction sets; they report the extent to which the syntax complies with the standards for transaction sets and functional groups. They do not report on the semantic meaning of the transaction sets (for example, on the ability of the receiver to comply with the request of the sender).


October 31, 2007 200

IMPLEMENTATION


Loop: ----- Usage: REQUIRED Repeat: 1 Example: ST*837*987654~

STANDARD


Level: Header Position: 010 Loop: ----- Requirement: Mandatory Max Use: 1 Purpose: To indicate the start of a transaction set and to assign a control number. Semantic: 1 The transaction set identifier (ST01) used by the translation routines of the interchange

partners to select the appropriate transaction set definition (e.g., 810 selects the invoice transaction set).

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

ST01

143

Transaction Set Identifier Code

R 3/3

M/Z ID 3/3

ST02

329

Transaction Set Control Number

R 4/9

M AN 4/9

ELEMENT SUMMARY

ST01 Transaction Set Identifier Code

Code uniquely identifying a Transaction Set

CODE DEFINITION 997 Functional Acknowledgment

ST02 Transaction Set Control Number

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

The Transaction Set Control Number in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). The number also aids in error resolution research. For example, start with the number 0001 and increment from there. Use the corresponding value in ST02 for this transaction set


October 31, 2007 201

IMPLEMENTATION

AK1 Functional Group Response Header

Usage: REQUIRED Repeat: 1 Example: AK1*FR*1~

STANDARD

AK1 Functional Group Response

Level: Header

Position: 020 Loop: ----- Requirement: Mandatory Max Use: 1 Purpose: To start acknowledgment of a functional group.

Set Notes: 1. AK1 is used to respond to the functional group header and to start the acknowledgment for a functional group. There shall be one AK1 segment for the functional group that is being acknowledged.

Semantic: 01 AK101 is the functional ID found in the GS segment (GS01) in the functional group being acknowledged.

02 AK102 is the functional group control number found in the GS segment in the functional group being acknowledged.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

AK101

479

Functional Identifier Code

R 2/2

M/Z ID 2/2

AK102

28


R 1/9

M/Z N0 1/9

ELEMENT SUMMARY

AK101 Functional Identifier Code

Code identifying a group of application related Transaction Sets.

CODE DEFINITION HC Health Care Claim (837)

AK102 Group Control Number



October 31, 2007 202

IMPLEMENTATION

AK2 Transaction Set Response Header

Loop: TRANSACTION SET RESPONSE HEADER Repeat: 999999 Usage: OPTIONAL Repeat: 1 Example: AK2*837*0005~

STANDARD

AK2 Transaction Set Response

Level: Header Position: 030 Loop: AK2 Repeat: 999999 Requirement: Optional Max Use: 1 Purpose: To start acknowledgment of a single transaction set. Set Notes: 1 AK2 is used to start the acknowledgment of a transaction set within the received functional

group. The AK2 segments shall appear in the same order as the transaction sets in the functional group that has been received and is being acknowledged.

Semantic: 01 AK201 is the transaction set ID found in the ST segment (ST01) in the transaction set being acknowledged.

02 AK202 is the transaction set control number found in the ST segment in the transaction set being acknowledged.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

AK201

143

Transaction Set Identifier Code

R 3/3

M/Z ID 3/3

AK202

329


R 4/9

M/Z N0 4/9

ELEMENT SUMMARY

AK201 Transaction Set Identifier Code

Code uniquely identifying a Transaction Set.

CODE DEFINITION 837 Health Care Claim

AK202 Transaction Set Control Number

Identifying control number that must be unique within the transaction set functional group assigned by the originator of a transaction set.


October 31, 2007 203

IMPLEMENTATION

AK3 Data Segment Note

Loop: DATA SEGMENT NOTE Repeat: 999999 Usage: OPTIONAL Repeat: 1 Example: AK3*NM1*37~

STANDARD

AK3 Data Segment Note

Level: Header Position: 040 Loop: AK2/AK3 Repeat: 999999 Requirement: Optional Max Use: 1 Purpose: To report errors in a data segment and to identify the location of the data segment. Set Notes: 1. The data segments of this standard are used to report the results of the syntactical analysis

of the functional groups of transaction sets; they report the extent to which the syntax complies with the standards for transaction sets and functional groups. They do not report on the semantic meaning of the transaction sets (for example, on the ability of the receiver to comply with the request of the sender).

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

AK301

721

Segment ID Code

R 2/3

M ID 2/3

AK302

719

Segment Position in Transaction Set

R 1/6

M N0 1/6

AK303

447

Loop Identifier Code

O 1/4

O AN 1/4

AK304

720

Segment Syntax Error Code

O 1/3

O ID 1/3

ELEMENT SUMMARY

AK301 Segment ID Code

Code defining the segment ID of the data segment in error. See Appendix A - Number 77.

This is the 2 or 3 characters which occur at the beginning of a segment.


October 31, 2007 204

AK302 Segment Position in Transaction Set

The numerical count position of this data segment from the start of the transaction set; the transaction set header is count position 1.

This is a data count, not a segment position in the standard description.

AK303 Loop Identifier Code

The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE.

Code identifying a loop within the transaction set which is bounded by the related LS and LE segments (corresponding LS and LE segments must have the same value for loop identifier). (Note: The loop ID number given on the transaction set diagram is recommended as the value for this data element in the segments LS and LE).

AK304 Segment Syntax Error Code

Code indicating error found based on the syntax editing of a segment.

CODE DEFINITION 1 Unrecognized Segment ID 2 Unexpected Segment 3 Mandatory Segment Missing 4 Loop Occurs Over Maximum Times 5 Segment Exceeds Maximum Use 6 Segment Not in Defined Transaction Set 7 Segment Not in Proper Sequence 8 Segment Has Data Element Errors


October 31, 2007 205

IMPLEMENTATION

AK4 Data Element Note

Loop: DATA SEGMENT NOTE Usage: OPTIONAL Repeat: 99 Example: AK4*1*98*7~

STANDARD

AK4 Data Element Note

Level: Header Position: 050 Loop: AK2/AK3

Requirement: Optional Max Use: 99 Purpose: To report errors in a data element and to identify the location of the data element.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

AK401

C030

Position in Segment

R

M

AK401-1

722

Element Position in Segment

R 1/2

M N0 1/2

AK401-2

1528

Component Data Element Position in Composite

O 1/2

O N0 1/2

AK402

725

Data Element Reference Number

O 1/4

O N0 1/4

AK403

723

Data Element Error Code

R 1/3

M ID 1/3

AK404

724

Copy of Bad Data Element

O 1/99

O AN 1/99


October 31, 2007 206

ELEMENT SUMMARY

AK401 Position in Segment

Code indicating the relative position of a simple data element, or the relative position of a composite data structure combined with the relative position of the component data element within the composite data structure, in error; the count starts with 1 for the simple data element or composite data structure immediately following the segment ID.

AK401-1 Element Position in Segment

This is used to indicate the relative position of a simple data element, or the relative position of a composite data structure with the relative position of the component within the composite data structure, in error; in the data segment the count starts with 1 for the simple data element or composite data structure immediately following the segment ID.

AK401-2 Component Data Element Position in Composite

To identify the component data element position within the composite that is in error.

AK402 Data Element Reference Number Reference number used to locate the data element in the Data Element Dictionary.

The Data Element Reference Number for this data element is 725. All reference numbers are found with the segment descriptions in this guide.

AK403 Data Element Syntax Error Code Code indicating the error found after syntax edits of a data element.

CODE DEFINITION 1 Mandatory Data Element Missing 2 Conditional Required Data Element Missing 3 Too Many Data Elements 4 Data Element Too Short 5 Data Element Too Long 6 Invalid Character in Data Element 7 Invalid Code Value 8 Invalid Date 9 Invalid Time 10 Exclusion Condition Violated

AK404 Copy of Bad Data Element This is a copy of the data element in error.


October 31, 2007 207

IMPLEMENTATION

AK5 Transaction Set Response Trailer

Loop: DATA SEGMENT NOTE Usage: REQUIRED Repeat: 1 Example: AK5*E*5~

STANDARD

AK5 Transaction Set Response Trailer

Level: Header Position: 060 Loop: AK2 Requirement: Mandatory Max Use: 1 Purpose: To acknowledge acceptance or rejection and to report errors in a transaction set.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

AK501

717

Transaction Set Acknowledgment Code

M 1/1

M ID 1/1

AK502

718

Transaction Set Syntax Error Code

O 1/3

O ID 1/3

AK503

718


O 1/3

O ID 1/3

AK504

718


O 1/3

O ID 1/3

AK505

718


O 1/3

O ID 1/3

AK506

718


O 1/3

O ID 1/3


October 31, 2007 208

ELEMENT SUMMARY

AK501 Transaction Set Acknowledgment Code

Code indicating accept or reject condition based on the syntax editing of the transaction set. CODE DEFINITION A Accepted (ADVISED) E Accepted But Errors Were Notes M Rejected Message Authentication Code (MAC) Failed R Rejected (ADVISED) W Rejected, Assurance Failed Validity Tests X Rejected, Content After Decryption Could Not Be Analyzed

AK502 Transaction Set Syntax Error Code Code indicating error found based on the syntax editing of a transaction set. This element is required if an error exists CODE DEFINITION 1 Transaction Set Not Supporting 2 Transaction Set Trail Missing 3 Transaction Set Control Number in Header and Trailer Do Not Match 4 Number of Included Segments Does Not Match Actual Count 5 One or More Segments in Error 6 Missing or Invalid Transaction Set Identifier 7 Missing or Invalid Transaction Set Control Number 8 Authentication Key Name Unknown 9 Encryption Key Name Unknown 10 Requested Service (Authentication or Encrypted) Not Available 11 Unknown Security Recipient 12 Incorrect Message Length (Encryption Only) 13 Message Authentication Code Failed 15 Unknown Security Originator 16 Syntax Error in Decrypted Text 17 Security Not Supported 23 Transaction Set Control Number Not Unique within the Functional Group 24 S3E Security End Segment Missing for S3S Security Start Segment 25 S3S Security Start Segment Missing for S3E Security End Segment 26 S4E Security End Segment Missing for S4S Security Start Segment 27 S4S Security Start Segment Missing for S4E Security End Segment

AK503 Transaction Set Syntax Error Code

Code indicating error found based on the syntax editing of a transaction set.

Use the same codes that were listed in AK502.

AK504 Transaction Set Syntax Error Code Code indicating error found based on the syntax editing of a transaction set.


AK505 Transaction Set Syntax Error Code

Code indicating error found based on the syntax editing of a transaction set.


AK506 Transaction Set Syntax Error Code Code indicating error found based on the syntax editing of a transaction set. Use the same codes that were listed in AK502.


October 31, 2007 209

IMPLEMENTATION

AK9 Functional Group Response Trailer

Usage: REQUIRED Repeat: 1 Example: AK9*A*2*2*2~

STANDARD

AK9 Functional Group Response Trailer

Level: Header

Position: 070 Loop: -------- Requirement: Mandatory Max Use: 1 Purpose: To acknowledge acceptance or rejection of a functional group and report the number of

included transaction sets from the original trailer, the accepted sets, and the received sets in this functional group.

Comments: A If AK901 is 'A' or 'E', then the transmitted functional group is accepted. If AK901 is 'R', then the transmitted group is rejected.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12

Attributes AK901

715

Functional Group Acknowledge Code

R 1/1

M ID 1/1

AK902

97

Number of Transaction Sets Included

R 1/6

M N0 1/6

AK903

123

Number of Received Transaction Sets

R 1/6

M N0 1/6

AK904

2

Number of Accepted Transaction Sets

R 1/6

M N0 1/6

AK905

716

Functional Group Error Code

O 1/3

O ID 1/3

AK906

716


O 1/3

O ID 1/3

AK907

716


O 1/3

O ID 1/3

AK908

716


O 1/3

O ID 1/3

AK909

716


O 1/3

O ID 1/3


October 31, 2007 210

ELEMENT SUMMARY

AK901 Functional Group Acknowledge Code

Code indicating accept or reject condition based on the syntax editing of the functional group.

CODE DEFINITION A Accepted/ADVISED E Accepted, But Errors Were Noted P Partially Accepted, At Least One Transaction Set Was Rejected /

ADVISED R Rejected / ADVISED

AK902 Number of Transaction Sets Included

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element.

This is the value of the original GE01.

AK903 Number of Received Transaction Sets Number of Transaction Sets received.

AK904 Number of Accepted Transaction Sets

Number of accepted Transaction Sets in a Functional Group.

AK905 Functional Group Syntax Error Code Code indicating error found based on the syntax editing of the functional group header and/or trailer.

CODE DEFINITION 1 Functional Group Not Supported 2 Functional Group Version Not Supported 3 Functional Group Trailer Missing 4 Group Control Number in the Functional Group Header and Trailer Do

Not Agree 5 Number of Included Transaction Sets Does Not Match Actual Count 6 Group Control Number Violates Syntax

AK906 Functional Group Syntax Error Code

Code indicating error found based on the syntax editing of the functional group header and/or trailer.






AK909 Functional Group Syntax Error Code

Code indicating error found based on the syntax editing of the functional group header and/or trailer.



October 31, 2007 211

IMPLEMENTATION


Usage: REQUIRED Repeat: 1 Example: SE*67*0001~

STANDARD


Level: Header Position: 080 Loop: ---- Requirement: Mandatory Max Use: 1 Purpose: To indicate the end of a transaction set and to provide a count of the transmitted segments. Comment: 1 SE is the last segment of each transaction set.

DIAGRAM

Seq. No.

Ref. No.

ASC X12 Name

SF

Req.

ASC X12 Attributes

SE01

096

Number of Included Segments

R 1/10

M N0 1/10

SE02

329


R 4/9

M AN 4/9

ELEMENT SUMMARY

SE01 Number of Included Segments

Total number of segments included in a transaction set including ST and SE segments

SE02 Transaction Set Control Number Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). The number also aids in error resolution research. For example, start with the number 0001 and increment from there.


October 31, 2007 212

C Code Lists and External Code Sources

4 ABA Routing Number

SIMPLE DATA ELEMENT REFERENCE 20 SIMPLE CODE REFERENCE 66/13 506/01 647/806 SOURCE Key to American Bankers Association Routing Numbers AVAILABLE FROM Rank McNally & Company P.O. Box 7600 Chicago, IL 60680 ABSTRACT Contains the Federal Reserve Routing Codes. The first four digits identify the Federal Reserve District, the next four the Institution, and the last is a check digit.

5 Countries, Currencies and Funds

SIMPLE DATA ELEMENT/CODE REFERENCES 235/CH, 26, 100 SOURCE Codes for Representation of Names of Countries, ISO 3166-(Latest Release) Codes for Representation of Currencies and Funds, ISO 4217-(Latest Release) AVAILABLE FROM American National Standards Institute 11 West 42nd Street, 13th Floor New York, NY 10036 ABSTRACT This international standard provides a two-letter alphabetic code for representing the names of countries, dependencies, and other areas of special geopolitical interest for the purposes of international exchange and general directions for the maintenance of the code. The standard is intended for use in any application requiring expression of entities in coded form. Most currencies are those of geopolitical entities that are listed in ISO 3166, Codes for the Representation of Names of Countries. The code may be a three-character alphabetic or three-digit numeric. The two leftmost characters or the alphabetic code identify the currency authority to which the code is assigned (using the two character alphabetic code from ISO 3166, if applicable). The rightmost character is a mnemonic derived from the name of the major currency unit of fund. For currencies not associated with a single geographic entity, a specially- allocated two-character alphabetic code, in the range XA to XZ identifies the currency authority. The rightmost character is derived from the name of the geographic area concerned, and is mnemonic to the extent possible. The numeric codes are identical to those assigned to the geographic entities listed in ISO 3166. The range 950-998 is reserved for identification of funds and currencies not associated with a single entity listed in ISO 3166.


October 31, 2007 213

22 States and Outlying Areas of the U.S.

SIMPLE DATA ELEMENT/CODE REFERENCES 66/SJ, 771/009, 235/A5, 156 SOURCE National Zip Code and Post Office Directory AVAILABLE FROM U.S. Postal Service National Information Data Center P.O. Box 2977 Washington, DC 20013 ABSTRACT Provides names, abbreviations, and codes for the 50 states, the District of Columbia, and the outlying areas of the U.S. The entities listed are considered to be the first order divisions of the U.S. Microfiche available from NTIS (same as address above). The Canadian Post Office lists the following as "official" codes for Canadian Provinces: AB - Alberta BC - British Columbia MB - Manitoba NB - New Brunswick NF - Newfoundland NS - Nova Scotia NT - North West Territory ON - Ontario PE - Prince Edward Island PQ - Quebec SK - Saskatchewan YT - Yukon

51 ZIP Code

SIMPLE DATA ELEMENT/CODE REFERENCES 66/16, 309/PQ, 309/PR, 309/PS, 771/010, 116 SOURCE National ZIP Code and Post Office Directory, Publication 65 AVAILABLE FROM U.S. Postal Service Washington, DC 20260 ABSTRACT The ZIP Code is a geographic identifier of areas within the United States and its territories for purposes of expediting mail distribution by the U.S. Postal Service. It is five or nine numeric digits. The ZIP Code structure divides the U.S. into ten large groups of states. The leftmost digit identifies one of these groups. The next two digits identify a smaller geographic area within the large group. The two rightmost digits identify a local delivery area. In the nine-digit ZIP Code, the four digits that follow the hyphen further subdivide the delivery area. The two leftmost digits identify a sector which may consist of several large buildings, blocks or groups of streets, a floor of a building, or a cluster of mailboxes. The USPS Domestic Mail Manual includes information on the use of the new 11-digit zip code.


October 31, 2007 214

D Change Summary

This is the second version for Health Care Paper Bills: Institutional Implementation Guide (IG) for the 837. This section will contain a summary of all changes made to the Institutional IG version 1.1. Changes made to the 837 Institutional:

1. 2010AA NM1 – Billing Provider Name changed to Billing Provider ID. 2. 2010AA NM103, N301, N401, N402 – Added UB92 reference for Medicaid bill types and guidance is given for

handling the National Provider ID (NPI). 3. 2010AA N403, NM108, NM109, REF01, REF02 – Added UB92 reference for Medicaid bill types and guidance is

given for handling the National Provider ID (NPI). 4. 2010AB NM1 – Pay to Provider Name changed to Pay to Provider ID. 5. 2010AB NM103, N301, N401, N402 – Added UB92 reference for Medicaid bill types and guidance is given for

handling the National Provider ID (NPI). 6. 2010AB N403, NM108, NM109, REF01, REF02 – Added UB92 reference for Medicaid bill types and guidance is

given for handling the National Provider ID (NPI). 7. 2300 CLM05/CLM05-01 – Default values are indicated if not present or unavailable. 8. 2300 CL1/CL103 – Added paper form equivalent for UB92 and UB04. 9. 2300 HI/HI01-02 (Principal Admitting E-code) – UB Box number changed from 67 to 69. 10. 2300 HI/HI02 (Principal Admitting E-code) – UB Box number changed from 76 to 69. 11. 2300 HI/HI02-02 (Principal Admitting E-code) – UB Box number changed from 76 to 69. 12. 2300 HI/HI03-02 (Principal Admitting E-code) - UB Box number changed from 77 to 72. 13. 2300 HI/HI01 (Other Diagnosis Information) – UB Box number changed from 68 to 67A. 14. 2300 HI/HI01-02 (Other Diagnosis Information) – UB Box number changed from 68 to 67A. 15. 2300 HI/HI02 (Other Diagnosis Information) - UB Box number changed from 69 to 67B-H. 16. 2300 HI/HI02-02 (Other Diagnosis Information) - UB Box number changed from 69 to 67B-H. 17. 2300 HI/HI03 (Other Diagnosis Information) - UB Box number changed from 70 to 67B-H. 18. 2300 HI/HI03-02 (Other Diagnosis Information) - UB Box number changed from 70 to 67B-H. 19. 2300 HI/HI04 (Other Diagnosis Information) - UB Box number changed from 71 to 67B-H. 20. 2300 HI/HI04-02 (Other Diagnosis Information) - UB Box number changed from 71 to 67B-H. 21. 2300 HI/HI05 (Other Diagnosis Information) - UB Box number changed from 72 to 67B-H. 22. 2300 HI/HI05-02 (Other Diagnosis Information) - UB Box number changed from 72 to 67B-H. 23. 2300 HI/HI06 (Other Diagnosis Information) - UB Box number changed from 73 to 67B-H. 24. 2300 HI/HI06-02 (Other Diagnosis Information) - UB Box number changed from 73 to 67B-H. 25. 2300 HI/HI07 (Other Diagnosis Information) - UB Box number changed from 74 to 67B-H. 26. 2300 HI/HI07-02 (Other Diagnosis Information) - UB Box number changed from 74 to 67B-H. 27. 2300 HI/HI08 (Other Diagnosis Information) - UB Box number changed from 75 to 67B-H. 28. 2300 HI/HI08-02 (Other Diagnosis Information) - UB Box number changed from 75 to 67B-H. 29. 2300 HI/HI01 (Principal Procedure Information) – UB Box number changed from 80 to 74. 30. 2300 HI/HI01-02 (Principal Procedure Information) – UB Box number changed from 80 to 74. 31. 2300 HI/HI01 (Other Procedure Information) – UB Box number changed from 81 to 74A. 32. 2300 HI/HI01-02 (Other Procedure Information) – UB Box number changed from 81 to 74A. 33. 2300 HI/HI02 (Other Procedure Information) – UB Box number changed from 81B to 74B-E. 34. 2300 HI/HI02-02 (Other Procedure Information) – UB Box number changed from 81B to 74B-E. 35. 2300 HI/HI02-04 (Other Procedure Information) – UB Box number changed from 81B to 74B-E. 36. 2300 HI/HI03 (Other Procedure Information) – UB Box number changed from 81C to 74B-E. 37. 2300 HI/HI03-02 (Other Procedure Information) – UB Box number changed from 81C to 74B-E. 38. 2300 HI/HI03-04 (Other Procedure Information) – UB Box number changed from 81C to 74B-E. 39. 2300 HI/HI04 (Other Procedure Information) – UB Box number changed from 81D to 74B-E. 40. 2300 HI/HI04-02 (Other Procedure Information) – UB Box number changed from 81D to 74B-E. 41. 2300 HI/HI04-04 (Other Procedure Information) – UB Box number changed from 81D to 74B-E. 42. 2300B NM1/NM103 – Added information regarding No other coverage, Self Pay, and Individual. 43. 2400 DTP/DTP03 – Added default value information for all other bill types.


October 31, 2007 215

E Example

For the data converted Non-Medicare Bill ISA*00* *00* *ZZ*DCVTOSFI *ZZ*STATEFARMCORPINC *030110*1546*U*00401*000000142*0*T*:~ GS*HC*DCV837ASFI*STATEFARMINC*20030110*154636*1*X*004010~ ST*837*0001~ BHT*0019*00*000000001*20030110*154636~ NM1*41*2*KEYING FROM IMAGECORPORATION*****46*XXXXXXXXX~ NM1*40*2*STATE FARM INSURANCE COMPANIES~ HL*1**20*1~ NM1*85*2*KURLEY MEDICAL OFFICE*****XX*3860056011~ N3*ONE KURLEY DRIVE~ N4*SOUTH FIELD*MI*48034~ REF*EI*123456789~ HL*2*1*22*1~ SBR*P~ NM1*IL*1*COOPER*PATRICIA*D***MI*37644139103~ HL*3*2*23*0~ NM1*QC*1*COOPER*PATRICIA*D~ N3*10216 E POTTER ROA~ N4*DAVISON*MI*48423~ DMG*D8*19361220*F~ CLM*BABUJI363205*1.1***11:A:1***Y~ DTP*434*RD8*20020911-20020914~ DTP*435*D8*20020911~ CL1***01~ REF*D9*09112002OHO112345~ HI*BK:57410~ HI*BF:5680*BF:25000*BF:4019*BF:41401*BF:V4581~ HI*BR:5122:D8:20020911~ HI*BQ:5459:D8:20020911~ HI*BE:01:::1550****BE:A3:::20164.03~ LX*1~ SV2*120*HC:1*670*UN*1*670~ DTP*472*D8*20020911~ LX*2~ SV2*120*HC:1*1390*UN*2*695~ DTP*472*D8*20020911~ LX*3~ SV2*250*HC:1*490.93*UN*1~ DTP*472*D8*20020911~~ LX*4~ SV2*258*HC:1*29.1*UN*1~ DTP*472*D8*20020911~ LX*5~ SV2*270*HC:1*48.5*UN*1~ DTP*472*D8*20020911~ SE*43*0001~ GE*1*1~ IEA*1*000000142~


October 31, 2007 216

For the data converted Medicare Bill ISA*00* *00* *ZZ*DCVTOSFI *ZZ*STATEFARMCORPINC *030110*1546*U*00401*000000142*0*T*:~ GS*HC*DCV837ASFI*STATEFARMINC*20030110*154636*1*X*004010~ ST*837*0001~ BHT*0019*00*000000001*20030110*154636~ NM1*41*2*KEYING FROM IMAGECORPORATION*****46*XXXXXXXXXM~ NM1*40*2*STATE FARM INSURANCE COMPANIES~ HL*1**20*1~ NM1*85*2*KURLEY MEDICAL OFFICE*****XX*3860056011~ N3*ONE KURLEY DRIVE~ N4*SOUTH FIELD*MI*48034~ REF*EI*123456789~ HL*2*1*22*1~ SBR*P~ NM1*IL*1*COOPER*PATRICIA*D***MI*37644139103~ HL*3*2*23*0~ NM1*QC*1*COOPER*PATRICIA*D~ N3*10216 E POTTER ROA~ N4*DAVISON*MI*48423~ DMG*D8*19361220*F~ CLM*BABUJI363205*1.1***11:A:1***Y~ DTP*434*RD8*20020911-20020914~ DTP*435*D8*20020911~ CL1***01~ REF*D9*09112002OHO112345~ HI*BK:57410~ HI*BF:5680*BF:25000*BF:4019*BF:41401*BF:V4581~ HI*BR:5122:D8:20020911~ HI*BQ:5459:D8:20020911~ HI*BE:01:::1550****BE:A3:::20164.03~ SBR*S~ CAS*CO*96*555.52~ AMT*B6*375~ AMT*N1*873.75~ AMT*A8*275~ MIA*5*6~ NM1*PR*2*Medicare~ REF*F8*Medicare12345678~ LX*1~ SV2*001*HC:1*0*UN*1*670~ DTP*472*D8*20020911~ LX*2~ SV2*120*HC:1*1390*UN*2*695~ DTP*472*D8*20020911~ LX*3~ SV2*250*HC:1*490.93*UN*1~ DTP*472*D8*20020911~ LX*4~ SV2*258*HC:1*29.1*UN*1~ DTP*472*D8*20020911~ LX*5~ SV2*270*HC:1*48.5*UN*1~ DTP*472*D8*20020911~ SE*51*0001~ GE*1*1~ IEA*1*000000142~


October 31, 2007 217

For the data converted Medicaid Bill ISA*00* *00* *ZZ*DCVTOSFI *ZZ*STATEFARMCORPINC *030110*1546*U*00401*000000142*0*T*:~ GS*HC*DCV837ASFI*STATEFARMINC*20030110*154636*1*X*004010~ ST*837*0001~ BHT*0019*00*000000001*20030110*154636~ NM1*41*2*KEYING FROM IMAGECORPORATION*****46*XXXXXXXXXC~ NM1*40*2*STATE FARM INSURANCE COMPANIES~ HL*1**20*1~ NM1*85*2*KURLEY MEDICAL OFFICE*****XX*3860056011~ N3*ONE KURLEY DRIVE~ N4*SOUTH FIELD*MI*48034~ REF*EI*123456789~ NM1*87*2*PAY TO PROVIDER-ELLIS HOSPITAL*****24*123456789~ HL*2*1*22*1~ SBR*P~ NM1*IL*1*COOPER*PATRICIA*D***MI*37644139103~ HL*3*2*23*0~ NM1*QC*1*COOPER*PATRICIA*D~ N3*10216 E POTTER ROA~ N4*DAVISON*MI*48423~ DMG*D8*19361220*F~ CLM*BABUJI363205*1.1***11:A:1***Y~ DTP*434*RD8*20020911-20020914~ DTP*435*D8*20020911~ CL1***01~ REF*D9*09112002OHO112345~ HI*BK:57410~ HI*BF:5680*BF:25000*BF:4019*BF:41401*BF:V4581~ HI*BR:5122:D8:20020911~ HI*BQ:5459:D8:20020911~ HI*BE:01:::1550****BE:A3:::20164.03~ SBR*S~ AMT*C4*302.22~ NM1*PR*2*Medicaid~ LX*1~ SV2*001*HC:1*0*UN*1*670~ DTP*472*D8*20020911~ LX*2~ SV2*120*HC:1*1390*UN*2*695~ DTP*472*D8*20020911~ LX*3~ SV2*250*HC:1*490.93*UN*1~ DTP*472*D8*20020911~ LX*4~ SV2*258*HC:1*29.1*UN*1~ DTP*472*D8*20020911~ LX*5~ SV2*270*HC:1*48.5*UN*1~ DTP*472*D8*20020911~ SE*47*0001~ GE*1*1~ IEA*1*000000142~


October 31, 2007 218

For the data converted Medicare Summary Notice Bill ISA*00* *00* *ZZ*DCVTOSFI *ZZ*STATEFARMCORPINC *030110*1546*U*00401*000000142*0*T*:~ GS*HC*DCV837ASFI*STATEFARMINC*20030110*154636*1*X*004010~ ST*837*0001~ BHT*0019*00*000000001*20030110*154636~ NM1*41*2*KEYING FROM IMAGECORPORATION*****46*KEY_TIN_NO~ NM1*40*2*STATE FARM INSURANCE COMPANIES~ HL*1**20*1~ NM1*85*2*KURLEY MEDICAL OFFICE*****XX*3860056011~ N3*ONE KURLEY DRIVE~ N4*SOUTH FIELD*MI*48034~ REF*EI*123456789~ HL*2*1*22*1~ SBR*P~ NM1*IL*1*COOPER*PATRICIA*D***MI*37644139103~ HL*3*2*23*0~ NM1*QC*1*COOPER*PATRICIA*D~ N3*10216 E POTTER ROA~ N4*DAVISON*MI*48423~ DMG*D8*19361220*F~ CLM*BABUJI363205*1.1***11:A:1***N~ DTP*434*RD8*20020911-20020914~ DTP*435*D8*20020911~ CL1***01~ REF*D9*09112002OHO112345~ HI*BK:57410~ HI*BF:5680*BF:25000*BF:4019*BF:41401*BF:V4581~ HI*BR:5122:D8:20020911~ HI*BQ:5459:D8:20020911~ HI*BE:01:::1550****BE:A3:::20164.03~ SBR*S~ CAS*CO*96*555.52~ AMT*B6*375~ AMT*N1*873.75 AMT*A8*275 MIA*5*6~ NM1*PR*2*MSN~ REF*F8*MSN123456789~ LX*1~ SV2*001*HC:1*0*UN*1*670~ DTP*472*D8*20020911~ LX*2~ SV2*120*HC:1*1390*UN*2*695~ DTP*472*D8*20020911~ LX*3~ SV2*250*HC:1*490.93*UN*1~ DTP*472*D8*20020911~ LX*4~ SV2*258*HC:1*29.1*UN*1~ DTP*472*D8*20020911~ LX*5~ SV2*270*HC:1*48.5*UN*1~ DTP*472*D8*20020911~ SE*51*0001~ GE*1*1~ IEA*1*000000142~


October 31, 2007 219

Repriced Bill ISA*00* *00* *ZZ*XXXXXXXXX *ZZ*999999999 *060327*0840*U*00401*000001169*0*P*:~ GS*HC*XXXXXXXXX*999999999*20060327*0840*660*X*004010X096~ ST*837*0001~ BHT*0019*00*HICS*20060327*0840*CH~ REF*87*004010X096~ NM1*41*2*REPRICER*****46*XXXXXXXXX~ PER*IC*MIKE YAROSH*TE*999999949~ NM1*40*2*STATE FARM*****46*999999999~ HL*1**20*1~ NM1*85*2*NORTH MEMOIRAL MED CENTER*****24*410729979~ N3*3300 OAKDALE AVE N~ N4*ROBBINSDALE*MN*554222926~ HL*2*1*22*1~ SBR*P~ NM1*IL*1*CLARKE*ROBERT****MI*H81227362323~ NM1*PR*2*STATE FARM INSURANCE*****PI*31053~ HL*3*2*23*0~ PAT*21~ NM1*QC*1*CLARKE*ROBERT~ N3*1234 HIGHWAY 55~ N4*HAMEL*MN*553409605~ DMG*D8*19410726*M~ CLM*060146426-3*141.32***13:A:3***Y~ DTP*434*RD8*20060216-20060216~ CL1***01~ PWK*OZ~ REF*9A*105024086~ REF*D9*20060680000161623~ REF*F8*060690135E~ HI*BK:25000~ HI*BH:11:D8:20050909~ HI*BE:A1:::46.96~ HCP*02*116.73*24.59*411479744~ SBR*S~ NM1*PR*2*AVAILABLE~ LX*1~ SV2*0272*HC:A4222*30.01*UN*1~ DTP*472*RD8*20060216-20060216~ LX*2~ SV2*0272*HC:C1751*111.31*UN*1~ DTP*472*RD8*20060216-20060216~ SE*40*0001~ GE*1*660~ IEA*1*000001169~


October 31, 2007 220

END OF THE

STATE FARM INSURANCE COMPANIES

837 INSTITUTIONAL IMPLEMENTATION GUIDE

FOR PAPER CLAIMS MEDICAL BILLS

state farm insurance companies 837 health care institutional · the 837 institutional transaction...

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