MINNESOTA HEALTH CARE PROGRAMS Professional, Institutional, and Dental Claims
Minnesota Department of Human Services MINNESOTA HEALTH CARE PROGRAMS 837 Encounter Companion Guide to the HIPAA Implementation Guide Professional, Institutional, and Dental Claims FINAL Revision Date: 12/16/2013 - FINAL See Change Control page for Implementation Dates of Data Elements EDI Mapping Specifications - Introduction Page 2 of 77 CHANGE CONTROL Date Revised 09/19/2013 Revised By D.Preciado 09/19/2013 D. Preciado 09/25/2013 D. Preciado 11/04/2013 D. Preciado 11/25/2013 D. Preciado Revisions Red additions identify changes for TPL data capture (HMS implementation) Yellow highlighted red additions identify corrections to 837 Encounter Companion Guide Aqua highlighted additions identify fields for MCO PAID DATE in 837D Pink highlighted additions identify changes for Service Facility & Taxonomy Code Added DTP segment to Loop 2330B of 837D, 837I and 837P transactions. (HMS implementation) Implementation Date 03/01/2014 12/01/2013 01/01/2014 07/01/2014 03/01/2014 2 837 Encounter Companion Guide to the HIPAA Implementation Guide Contents 1 INTRODUCTION ......................................................................................................................................................................................................... 4 2 PROFESSIONAL ........................................................................................................................................................................................................ 5 ENVELOPE INFORMATION ....................................................................................................................................................................................... 25 3 INSTITUTIONAL ....................................................................................................................................................................................................... 27 ENVELOPE INFORMATION ....................................................................................................................................................................................... 52 4 DENTAL .................................................................................................................................................................................................................. 55 ENVELOPE INFORMATION ....................................................................................................................................................................................... 74 APPENDIX – PAID AMOUNT AND ALLOWED AMOUNT RULES ............................................................................................................................ 77 Minnesota Department of Human Services 3 837 Encounter Companion Guide to the HIPAA Implementation Guide 1 INTRODUCTION 1.1 Document Purpose Managed Care Organizations (MCOs) contracting with the Minnesota Department of Human Services (DHS) to provide prepaid health care services are required to provide encounter data in HIPAA compliant format. This companion guide further specifies the requirements to be used when preparing and submitting encounter data. Disclaimer The companion guide supplements, but does not contradict, disagree, oppose, or otherwise modify the HIPAA Implementation Guide in a manner that will make its implementation by users to be out of compliance. 1.2 Column Notations Req’d: Required elements may be marked as: • Required (Y) • Not required (N) • Conditional according to the 837 HIPAA implementation guide (C1) • Conditional according to DHS additional requirements (C2) Value: If a value is present in the DHS Requirements Value Column the values MUST be entered. If no value is present refer to the Descriptions column for instructions. Description Column: This column will describe the value in the value column or give instructions for what must be submitted in the value column. Minnesota Department of Human Services 4 2 PROFESSIONAL 837P HIPAA Implementation Guide Data LOOP SEGMENT HDR ST NAME ID HEADER TRANSACTION SET HEADER ST01 ST02 BHT 1000A ELEMENT NAME TRANSACTION SET IDENTIFIER CODE TRANSACTION SET CONTROL NUMBER ST03 IMPLEMENTATION CONVENTION REFERENCE BHT01 HIERARCHICAL STRUCTURE CODE BHT02 BHT03 BHT04 BHT05 BHT06 DHS Encounter Data REQ VALUE(S) DHS REQUIREMENT DESCRIPTION Y Y 837 HEALTH CARE CLAIM Y 005010X222 A1 MUST BE SAME AS GS08 Y Y 0019 INFORMATION SOURCE, SUBSCRIBER, DEPENDENT TRANSACTION SET PURPOSE CODE Y 00 ORIGINAL 18 REFERENCE IDENTIFICATION DATE TIME TRANSACTION TYPE CODE Y Y Y Y REISSUE SUBMISSION NUMBER-MCO ASSIGNED TRANSACTION SET CREATION DATE TRANSACTION SET CREATION TIME REPORTING THIS LOOP IS USED FOR INFORMATION REGARDING THE MCO RESPONSIBLE FOR THE ENCOUNTER. BEGIN OF HIERARCHICAL TXN Y MCO SYSTEM GENERATED NUMBER RP SUBMITTER NAME NM1 SUBMITTER NAME Y NM101 ENTITY IDENTIFIER CODE Y 41 NM102 ENTITY TYPE QUALIFIER Y 2 NM103 Y NM109 NAME LAST OR ORGANIZATION NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE PER01 CONTACT FUNCTION CODE Y PER02 NAME Y NM108 PER SUBMITTER EDI CONTACT INFO Minnesota Department of Human Services Y VALUE 41 SHOULD BE SUBMITTED EVEN THOUGH THIS IS MCO INFORMATION. NON-PERSON ENTITY MCO NAME (OR CONTRACTOR NAME) 46 Y Y TRADING PARTNER ID MCO UMPI NUMBER ASSIGNED BY DHS IC INFORMATION CONTACT MCO SUBMITTER CONTACT 5 837P HIPAA Implementation Guide Data LOOP SEGMENT NAME ID PER03 PER04 1000B NM1 HL PRV NM1 DHS REQUIREMENT DESCRIPTION COMMUNICATION NUMBER QUALIFIER COMMUNICATION NUMBER Y TE TELEPHONE NM109 HL01 HL03 HL04 HIERARCHICAL ID NUMBER HIERARCHICAL LEVEL CODE HIERARCHICAL CHILD CODE BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL HIERARCHICAL LEVEL BILLING PROVIDER SPECIALTY INFORMATION MCO CONTACT PHONE NUMBER 40 2 RECEIVER NON-PERSON ENTITY MN DEPT OF HUMAN SERVICES Y 46 TRADING PARTNER ID Y Y 411674742 RECEIVER ID Y Y Y Y PRV03 PROVIDER CODE REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION NM101 ENTITY IDENTIFIER CODE Y Y Y Y NM102 ENTITY TYPE QUALIFIER Y NM103 NAME LAST OR ORGANIZATION NAME Y NM104 NM108 NAME FIRST IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE C1 C1 BILLING PROVIDER NAME BILLING PROVIDER NAME NM109 Minnesota Department of Human Services Y Y Y Y Y Y 20 1 1 THEN INCREMENT BY 1 INFORMATION SOURCE ADDITIONAL SUBORDINATE HL DATA SEGMENT IN THIS HIERARCHICAL STRUCTURE C1 PRV01 PRV02 2010AA VALUE(S) ENTITY IDENTIFICAT CODE ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE NM108 2000A REQ RECEIVER NAME RECEIVER NAME NM101 NM102 NM103 DHS Encounter Data ELEMENT NAME Y Y BI PXC BILLING HEALTH CARE PROVIDER TAXONOMY CODE PROVIDER TAXONOMY CODE 85 BILLING PROVIDER Correction of QUALIFIER DESCRIPTION based on review of X12 implementation guide. PAY TO PROVIDER PERSON NON-PERSON ENTITY DEFAULT TO ANY TEXT-NOT USED BUT REQUIRED BY STANDARD BILLING PROVIDER LAST OR ORGANIZATIONAL NAME BILLING PROVIDER FIRST NAME NPI C1 1 2 XX BILLING PAY TO PROVIDER-NPI 6 837P HIPAA Implementation Guide Data LOOP SEGMENT N3 N4 REF 2000B HL SBR NAME ID REQ N301 ADDRESS INFORMATION Y Y N302 ADDRESS INFORMATION C1 Y N401 CITY NAME Y N402 STATE OR PROVINCE CODE N403 POSTAL CODE REF01 REFERENCE IDENTIFICATION QUALIFIER C1 Y C1 Y Y C1 Y REF02 BILLING PROVIDER TAX IDENTIFICATION NUMBER BILLING PROVIDER ADDRESS BILLING PROVIDER CITY/STATE/ZIP BILLING PROVIDER TAX IDENTIFICATION SUBSCRIBER HIERARCHICAL LEVEL HIERARCHICAL LEVEL VALUE(S) DHS REQUIREMENT DESCRIPTION DEFAULT TO ANY TEXT NOT USED BUT REQUIRED BY STANDARD BILLING PROVIDER ADDRESS LINE BILLING PROVIDER ADDRESS LINE “ANY TEXT” BILLING PROVIDER CITY NAME MN BILLING PROVIDER STATE OR PROVINCE CODE ANY ZIP CODE BILLING PROVIDER POSTAL ZONE OR ZIP CODE (9 DIGIT) EI Y PROVIDERS EMPLOYER IDENTIFICATION NUMBER PROVIDERS EMPLOYERS IDENTIFICATION NUMBER OR DEFAULT TO ANY NUMBER NEEDED FOR STANDARD Y HL01 HIERARCHICAL ID NUMBER Y Y HL02 HIERARCHICAL PARENT ID Y HL03 HL04 HIERARCHICAL LEVEL CODE HIERARCHICAL CHILD CODE Y Y 22 0 SBR01 PAYER RESPONSIBILITY SEQUENCE NUMBER CODE Y Y P PRIMARY S T 18 SECONDARY TERTIARY SELF MC MEDICAID SUBSCRIBER INFORMATION SBR02 SBR09 Minnesota Department of Human Services DHS Encounter Data ELEMENT NAME INDIVIDUAL RELATIONSHIP CODE CLAIM FILING INDICATOR CODE C1 Y C1 Y START WITH 2 AND INCREMENT BY 1. 1 FOR FIRST ITERATION. CHANGES TO PROVIDER HL01 VALUE WHEN PROVIDER NUMBER CHANGES IN A TRANSACTION SET. SUBSCRIBER NO SUBORDINATE HL SEGMENT IN THIS HIERARCHICAL STRUCTURE 7 837P HIPAA Implementation Guide Data LOOP SEGMENT 2010BA NM1 NAME ID REQ VALUE(S) DHS REQUIREMENT DESCRIPTION NM101 ENTITY IDENTIFIER CODE Y Y Y IL INSURED OR SUBSCRIBER NM102 NM103 ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME NAME FIRST 1 PERSON SUBSCRIBER LAST NAME SUBSCRIBER NAME SUBSCRIBER NAME NM104 NM105 NM108 N3 N4 DMG NM109 NAME MIDDLE IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE N301 ADDRESS INFORMATION SUBSCRIBER ADDRESS SUBSCRIBER CITY/STATE/ZIP N402 STATE OR PROVINCE CODE N403 POSTAL CODE DMG01 DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD GENDER CODE C2 Y C2 Y C2 Y Y PROPERTY AND CASUALTY CLAIM NUMBER Minnesota Department of Human Services MI Y Y SUBSCRIBER MIDDLE INITIAL, IF KNOWN MEMBER IDENTIFICATION NUMBER DHS ASSIGNED EIGHT DIGIT MEMBER ID SINCE THE PATIENT IS ALWAYS THE SUBSCRIBER UNDER MHCP, THIS SEGMENT IS REQUIRED. DEFAULT TO ANY TEXT – NOT USED BUT REQUIRED BY STANDARD. SINCE THE PATIENT IS ALWAYS THE SUBSCRIBER UNDER MHCP, THIS SEGMENT IS REQUIRED. DEFAULT TO ANY TEXT – NOT USED BUT REQUIRED BY STANDARD DEFAULT TO ANY TEXT – NOT USED BUT REQUIRED BY STANDARD DEFAULT TO “00000”. Y Y D8 U F M DATE EXPRESSED IN FORMAT CCYYMMDD SUBSCRIBER BIRTH DATE UNKNOWN (DEFAULT) FEMALE MALE Y4 AGENCY CLAIM NUMBER C2 REF02 NM1 SUBSCRIBER FIRST NAME Y C2 CITY NAME SUBSCRIBER DEMOGRAPHICS PAYER NAME PAYER NAME C2 Y C1 Y N401 REF01 2010BB Y Y C2 DMG02 DMG03 REF DHS Encounter Data ELEMENT NAME REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION Y Y Y Y MCO’S OWN MEMBER ID 8 837P HIPAA Implementation Guide Data LOOP SEGMENT NAME ID REQ VALUE(S) DHS REQUIREMENT DESCRIPTION ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE Y Y Y PR 2 PAYER NON-PERSON ENTITY MN DEPT OF HUMAN SERVICES Y PI PAYER ID Y C1 411674742 DHS PAYER ID REF01 REFERENCE IDENTIFICATION QUALIFIER Y G2 REF02 REFERENCE IDENTIFICATION Y Y (REPLACES 2010AA PAY TO PROVIDER UMPI) PROVIDER COMMERCIAL NUMBER UMPI OF BILLING PAY TO PROVIDER CLM01 CLAIM SUBMITTER’S IDENTIFIER Y MCO’S OWN CLAIM NUMBER (ICN) CLM02 MONETARY AMOUNT Y TOTAL CLAIM CHARGE AMOUNT (BILLED AMOUNT) PER APPENDIX A IN THE IMPLEMENTATION GUIDE, DECIMAL DATA ELEMENTS IN DATA ELEMENT 782 WILL BE LIMITED TO A MAXIMUM LENGTH OF 10 CHARACTERS INCLUDING REPORTED OR IMPLIED PLACES FOR CENTS. CLM05 HEALTH CARE SERVICE LOCATION INFORMATION FACILITY CODE VALUE Y FACILITY CODE QUALIFIER Y B CLAIM FREQUENCY TYPE CODE (CLAIM SUBMISSION REASON CODE) Y 1 PLACE OF SERVICE CODE FOR PROFESSIONAL OR DENTAL SERVICES ORIGINAL Y 7 8 Y REPLACEMENT VOID YES (DEFAULT) N NO NM101 NM102 NM103 NM108 NM109 REF 2300 CLM BILLING PROVIDER SECONDARY IDENTIFICATION CLAIM INFORMATION CLAIM INFORMATION CLM051 CLM052 CLM053 CLM06 Minnesota Department of Human Services DHS Encounter Data ELEMENT NAME YES/NO CONDITION OR RESPONSE CODE (PROVIDER SIGNATURE ON FILE) Y PLACE OF SERVICE CODE 9 837P HIPAA Implementation Guide Data LOOP SEGMENT NAME ID CLM07 CLM08 DHS Encounter Data ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION PROVIDER ACCEPT ASSIGNMENT CODE (MEDICARE ASSIGNMENT CODE) Y A ASSIGNED (DEFAULT) B ASSIGNMENT ACCEPTED FOR CLINICAL LAB SERVICES ONLY NOT ASSIGNED YES (DEFAULT) YES/NO CONDITION OR RESPONSE CODE (ASSIGNMENT OF BENEFITS INDICATOR) Y C Y N W CLM09 RELEASE OF INFORMATION CODE Y Y I CLM10 CLM11 CLM111 THRU CLM113 DTP ONSET OF CURRENT ILLNESS Minnesota Department of Human Services PATIENT SIGNATURE SOURCE CODE RELATED CAUSES INFORMATION RELATED CAUSES CODE NO PATIENT REFUSES TO ASSIGN BENEFITS YES, PROVIDER HAS A SIGNED STATEMENT PERMITTING RELEASE OF MEDICAL BILLING DATA RELATED TO A CLAIM (DEFAULT) INFORMED CONSENT TO RELEASE MEDICAL INFORMATION FOR CONDITIONS OR DIAGNOSES REGULATED BY FEDERAL STATUTES C1 P SIGNATURE GENERATED BY PROVIDER IF THE PATIENT WAS NOT PHYSICALLY PRESENT FOR SERVICES AA AUTO ACCIDENT EM OA EMPLOYMENT OTHER ACCIDENT REQUIRED IF CLM11-1, -2 or -3 = AA TO IDENTIFY THE STATE IN WHICH THE AUTOMOBILE ACCIDENT OCCURRED. USE THE STATE POSTAL CODE. REQUIRED IF THE AUTOMOBILE ACCIDENT OCCURRED OUT OF THE UNITED STATES. C1 Y CLM114 STATE OR PROVINCE CODE C1 CLM115 COUNTRY CODE C1 C1 10 837P HIPAA Implementation Guide Data LOOP SEGMENT DTP AMT REF NAME ID REQ VALUE(S) DHS REQUIREMENT DESCRIPTION DTP01 DATE/TIME QUALIFIER Y 431 ONSET OF CURRENT ILLNESS DTP02 Y D8 DATE EXPRESSED IN CCYYMMDD DTP03 DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD DTP01 DATE/TIME QUALIFIER DTP02 ACCIDENT DATE ACCIDENT Y D8 DATE EXPRESSED IN CCYYMMDD DTP03 DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD AMT01 AMOUNT QUALIFIER CODE Y AMT02 MONETARY AMOUNT Y ORIGINAL REFERENCE NUMBER (ICN/DCN) Minnesota Department of Human Services ONSET OF CURRENT ILLNESS DATE IN CCYYMMDD FORMAT. 439 PATIENT AMOUNT PAID FILE INFORMATION Y C1 Y Y C1 ACCIDENT DATE ALL TPL AND/OR MEDICARE PAYMENT INFORMATION IS SENT IN THIS SEGMENT WHETHER THE PAYMENT IS FROM THE PATIENT OR THE PROVIDER. F5 PATIENT AMOUNT PAID. ENTER IF APPLICABLE. ENTER TOTAL TPL AND OR MEDICARE PAYMENT HERE, IF APPLICABLE. PER APPENDIX A IN THE IMPLEMENTATION GUIDE, DECIMAL DATA ELEMENTS IN DATA ELEMENT 782 WILL BE LIMITED TO A MAXIMUM LENGTH OF 10 CHARACTERS INCLUDING REPORTED OR IMPLIED PLACES FOR CENTS. C1 REF01 K3 DHS Encounter Data ELEMENT NAME REF02 PAYER CLAIM CONTROL NUMBER REFERENCE IDENTIFICATION K3 K301 FIXED FORMAT INFORMATION Y Y C1 Y F8 ORIGINAL REFERENCE NUMBER MCO’S ORIGINAL CLAIM (ICN) NUMBER. USED WHEN CLM05-3 IS 7REPLACEMENT OR 8-VOID. THIS IS FOR REPLACEMENT CLAIM OR VOID CLAIM USAGE ONLY. FOR STATE OF JURISDICTION AND TOOTH NUMBER/ORAL CAVITY. 11 837P HIPAA Implementation Guide Data LOOP SEGMENT CRC NAME ID EPSDT REFERRAL CRC ELEMENT NAME DHS Encounter Data REQ VALUE(S) DHS REQUIREMENT DESCRIPTION THIS SEGMENT IS SENT FOR CHILD AND TEEN CHECKUP CLAIMS. MUTUALLY DEFINED. EPSDT SCREEN REFERRAL INFORMATION. NO C1 CRC01 CODE CATEGORY Y ZZ CRC02 YES/NO CONDITION OR RESPONSE CODE (WAS AN EPSDT REFERRAL GIVEN TO THE PATIENT?) Y N CRC03 CONDITION INDICATOR Y Y AV NU S2 ST HI HEALTH CARE INFORMATION CODES HI01 HEALTH CARE CODE INFORMATION CODE LIST QUALIFIER CODE Y HI01-2 HI102 THRU HI12 HI02-1 THRU HI12-1 INDUSTRY CODE HEALTH CARE CODE INFORMATION Y C1 CODE LIST QUALIFIER CODE(S) Y HI02-2 THRU HI12-2 HI01 THRU HI12 INDUSTRY CODE Y ICD-10-CM DIAGNOSIS CODE DIAGNOSIS CODE HEALTH CARE CODE INFORMATION C1 CONDITION CODE HI01-1 Y BK ABK BF ABF HI HEALTH CARE INFORMATION CODES Minnesota Department of Human Services YES AVAILABLE NOT USED. PATIENT REFUSED REFERRAL. NOT USED. THIS CONDITION INDICATOR MUST BE USED WHEN THE SUBMITTER ANSWERS “N” IN CRC02. UNDER TREATMENT-PATIENT IS CURRENTLY UNDER TREATMENT FOR REFERRED DIAGNOSTIC OR CORRECTIVE HEALTH PROBLEM. NEW SERVICES REQUESTED. REFERRAL TO ANOTHER PROVIDER FOR DIAGNOSTIC OR CORRECTIVE TREATMENT/SCHEDULED FOR ANOTHER APPOINTMENT WITH SCREENING PROVIDER. DO NOT SEND DECIMAL POINTS IN THE DIAGNOSIS CODE. ICD-9-CM PRINCIPAL DIAGNOSIS ICD-10-CM PRINCIPAL DIAGNOSIS PRINCIPAL DIAGNOSIS CODE Added line based on review of X12 implementation guide. Only H101 is required when this HI segment is used. ICD-9-CM DIAGNOSIS CODE 12 837P HIPAA Implementation Guide Data LOOP SEGMENT NAME ID HI01-1 THRU HI12-1 HI01-2 THRU HI01-2 2310A NM1 REF REQ VALUE(S) DHS REQUIREMENT DESCRIPTION CODE LIST QUALIFIER CODE Y BG CONDITION INDUSTRY CODE Y REFERRING PROVIDER NAME INDIVIDUAL /ORG. NAME ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME NM104 NAME FIRST C1 NM108 IDENTIFICATION CODE QUALIFIER Y NM109 IDENTIFICATION CODE Y REFERRING PROVIDER SECONDARY IDENTIFICATION DN 1 XX REFERRING PROVIDER PERSON DEFAULT TO ANY TEXT – NOT USED BUT REQUIRED BY STANDARD DEFAULT TO ANY TEXT- REQUIRED IF “1” IS SENT IN NM102. NPI REFERRING PROVIDER NPI REF02 REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION NM101 ENTITY IDENTIFIER CODE Y Y 82 RENDERING PROVIDER NM102 ENTITY TYPE QUALIFIER Y 1 PERSON 2 NM103 NAME LAST OR ORGANIZATION NAME NAME FIRST Y IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE C1 NON-PERSON DEFAULT TO ANY TEXT- NOT USED BUT REQUIRED BY STANDARD DEFAULT TO ANY TEXT- REQUIRED IF “1” IS SENT IN NM102. NPI INDIVIDUAL /ORG. NAME NM104 NM108 NM109 Minnesota Department of Human Services CONDITION CODE C1 RENDERING PROVIDER NAME NM1 C1 Y Y Y Y NM101 NM102 NM103 REF01 2310B DHS Encounter Data ELEMENT NAME Y G2 PROVIDER COMMERCIAL NUMBER (FOR UMPI NUMBERS) DHS UMPI NUMBER. REQUIRED WHEN RENDERING PROVIDER INFORMATION IS DIFFERENT THAN PROVIDER LISTED IN LOOP 2010AA Y C2 C1 C1 XX RENDERING PROVIDER NPI NUMBER 13 837P HIPAA Implementation Guide Data LOOP SEGMENT REF NAME ID RENDERING PROVIDER SECONDARY IDENTIFICATION REF02 NM1 C1 ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE SERVICE FACILITY LOCATION ADDRESS DHS REQUIREMENT DESCRIPTION G2 PROVIDER COMMERCIAL NUMBER (FOR UMPI NUMBERS) DHS UMPI NUMBER. REQUIRED WHEN THE LOCATION OF HEALTH CARE SERVICE IS DIFFERENT THAN THAT CARRIED IN LOOP 2010AA Y Y Y 77 2 SERVICE LOCATION NON-PERSON ENTITY LABORATORY OR FACILITY NAME C1 XX NPI C1 LABORATORY OR FACILITY PRIMARY IDENTIFIER Y N301 ADDRESS INFORMATION Y N302 ADDRESS INFORMATION C1 Y N401 N402 CITY NAME STATE OR PROVINCE CODE Y C1 N403 POSTAL CODE C1 SERVICE FACILITY LOCATION CITY, STATE, ZIP CODE SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION LABORATORY OR FACILITY ADDRESS LINE LABORATORY OR FACILITY ADDRESS LABORATORY OR FACILITY CITY NAME LABORATORY OR FACILITY STATE OR PROVINCE CODE LABORATORY OR FACILITY POSTAL ZONE OR ZIP CODE C1 REF01 REF02 Minnesota Department of Human Services VALUE(S) Y SERVICE FACILITY LOCATION NAME NM109 REF Y C1 NM108 N4 REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION SERVICE FACILITY LOCATION NAME NM101 NM102 NM103 N3 DHS Encounter Data REQ C2 REF01 2310C ELEMENT NAME REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION Y Y G2 PROVIDER COMMERCIAL NUMBER (FOR UMPI NUMBERS) LABORATORY OR FACILITY SECONDARY IDENTIFIER (DHS UMPI NUMBER) 14 837P HIPAA Implementation Guide Data LOOP SEGMENT 2320 SBR NAME ID ELEMENT NAME DHS Encounter Data REQ OTHER SUBSCRIBER INFORMATION C2 OTHER SUBSCRIBER INFORMATION Y SBR01 SBR02 PAYER RESPONSIBILITY SEQUENCE NUMBER CODE INDIVIDUAL RELATIONSHIP CODE VALUE(S) THIS LOOP IS REQUIRED ONLY WHEN THERE ARE PHYSICIAN ADMINISTERED DRUGS AND THIRD PARTY LIABILITY ON THE CLAIM. IT IS REQUIRED SO THAT LINE LEVEL TPL CAN BE SUBMITTED FOR THE DRUGS. THIS LOOP IS REQUIRED – THE FIRST OCCURRENCE MUST CONTAIN INFORMATION FOR THE MCO AS THE PRIMARY/SECONDARY PAYER. IF THE PRIMARY PAYER IS A THIRD PARTY, THE SECOND OCCURRENCE OF THIS SEGMENT SHOULD CONTAIN A “P” AND INFORMATION RELATED TO THE RELEVANT THIRD PARTY PAYER. UP TO 10 SBR LOOPS CAN BE SENT. Y P PRIMARY SECONDARY TERTIARY REFER TO THE IMPLEMENTATION GUIDE FOR THE OTHER CODES/VALUES TO USE. Y S T SEE X12 IG FOR ADDT’L CODES/ VALUES 18 SEE X12 IG FOR ADDT’L CODES/ VALUES Minnesota Department of Human Services DHS REQUIREMENT DESCRIPTION SBR03 REFERENCE IDENTIFICATION C1 SBR05 INSURANCE TYPE CODE C1 SEE X12 IG FOR CODES/ VALUES SELF– this is the only option for the first occurrence. Subsequent occurrences should be billed as appropriate. REFER TO THE IMPLEMENTATION GUIDE FOR THE OTHER CODES/VALUES TO USE. INSURANCE GROUP OR POLICY NUMBER REQUIRED WHEN MEDICARE PRESENT AND MEDICARE IS NOT PRIMARY PAYER. REFER TO THE IMPLEMENTATION GUIDE FOR THE CODES/VALUES TO USE. 15 837P HIPAA Implementation Guide Data LOOP SEGMENT NAME ID SBR09 DHS Encounter Data ELEMENT NAME REQ VALUE(S) DHS REQUIREMENT DESCRIPTION CLAIM FILING INDICATOR CODE Y HM 11 HEALTH MAINTENANCE ORGANIZATION (HM) – This is only for the first occurrence. On subsequent occurrences, fill out as appropriate. OTHER NON-FEDERAL PROGRAMS REFER TO THE IMPLEMENTATION GUIDE FOR THE OTHER CODES/VALUES TO USE. SEE X12 IG FOR ADDT’L CODES/ VALUES CAS CLAIM LEVEL ADJUSTMENTS C1 CAS01 CLAIM ADJUSTMENT GROUP CODE Y CO CR OA PI PR CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19 AMT COB PAYER PAID AMOUNT Minnesota Department of Human Services CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY COMPLETE IF YOU HAVE CLAIM LEVEL ADJUSTMENTS CONTRACTUAL OBLIGATIONS Y CORRECTIONS AND REVERSALS OTHER ADJUSTMENTS PAYOR INITIATED REDUCTIONS PATIENT RESPONSIBILITY ADJUSTMENT REASON Y C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON C1 C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON C1 C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON C1 C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON C1 C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON C1 C1 C2 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY 16 837P HIPAA Implementation Guide Data LOOP SEGMENT NAME ID AMT01 AMT02 AMT AMT OI REQ VALUE(S) DHS REQUIREMENT DESCRIPTION AMOUNT QUALIFIER CODE MONETARY AMOUNT Y Y D PAYOR PAID AMOUNT PAYER PAID AMOUNT; ZERO IS ACCEPTABLE REMAINING PATIENT LIABILITY C1 AMT01 AMT02 AMOUNT QUALIFIER CODE MONETARY AMOUNT Y Y C1 EAF AMOUNT OWED REMAINING PATIENT LIABILITY AMT01 AMT02 AMOUNT QUALIFIER CODE MONETARY AMOUNT Y Y Y A8 NONCOVERED CHARGES – ACTUAL NON-COVERED CHARGE AMOUNT OI03 YES/NO CONDITION OR RESPONSE PATIENT SIGNATURE SOURCE CODE Y Y C1 P RELEASE OF INFORMATION Y C2 Y COB TOTAL NON-COVERED AMOUNT OTHER INSURANCE COVERAGE INFORMATION OI04 OI06 2330A OTHER SUBSCRIBER NAME NM1 OTHER SUBSCRIBER NAME NM101 NM102 ENTITY ID CODE ENTITY TYPE QUALIFIER NM103 NAME LAST OR ORGANIZATION NAME NAME FIRST NAME MIDDLE NAME SUFFIX ID CODE QUALIFIER ID CODE NM104 NM105 NM107 NM108 NM109 Minnesota Department of Human Services DHS Encounter Data ELEMENT NAME Y Y Y Y C1 C1 C1 Y Y SIGNATURE GENERATED BY PROVIDER AS THE PATIENT WAS NOT PHYSICALLY PRESENT FOR SERVICES THIS LOOP IS REQUIRED ONLY WHEN THERE ARE PHYSICIAN ADMINISTERED DRUGS AND THIRD PARTY LIABILITY ON THE CLAIM. IT IS REQUIRED SO THAT LINE LEVEL TPL CAN BE SUBMITTED FOR THE DRUGS. THIS LOOP IS REQUIRED – MCO ADJUDICATION INFORMATION AS A PAYER IS SUBMITTED HERE AND TPL ADJUDICATION INFORMATION, INCLUDING PHYSICIAN ADMINISTERED DRUGS. ONE SUBSCRIBER NAME PER SBR SEGMENT. IL 1 2 UNKNOWN MI UNKNOWN INSURED OR SUBSCRIBER PERSON NON-PERSON ENTITY OTHER INSURED LAST NAME OTHER INSURED FIRST NAME OTHER INSURED MIDDLE INITIAL NAME OTHER INSURED NAME SUFFIX MEMBER IDENTIFICATION NUMBER 17 837P HIPAA Implementation Guide Data LOOP SEGMENT 2330B NAME ID ELEMENT NAME OTHER PAYER NAME NM1 OTHER PAYER NAME NM108 NM109 SV1 PROFESSIONAL SERVICE PAYER NON-PERSON ENTITY Y PI PAYOR IDENTIFICATION OTHER PAYER PRIMARY IDENTIFIER DHS UMPI NUMBER ASSIGNED TO THE MANAGED CARE ORGANIZATION Y Y REF02 REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION LX01 ASSIGNED NUMBER SV101 COMPOSITE MEDICAL PROCEDURE IDENTIFIER PRODUCT/SERVICE ID QUALIFIER SV1011 Minnesota Department of Human Services PR 2 UNKNOWN Y Y REF01 LX THIS LOOP IS REQUIRED ONLY WHEN THERE ARE PHYSICIAN ADMINISTERED DRUGS AND THIRD PARTY LIABILITY ON THE CLAIM. IT IS REQUIRED SO THAT LINE LEVEL TPL CAN BE SUBMITTED FOR THE DRUGS. THIS LOOP IS REQUIRED – MCO ADJUDICATION INFORMATION AS A PAYER IS SUBMITTED HERE AND TPL ADJUDICATION INFORMATION, INCLUDING PHYSICIAN ADMINISTERED DRUGS. ONE OTHER PAYER NAME PER SBR SEGMENT. Y Y Y Y DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD OTHER PAYER CLAIM CONTROL NUMBER SERVICE LINE SERVICE LINE DHS REQUIREMENT DESCRIPTION C1 DTP03 2400 ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE CLAIM CHECK OR REMITTANCE DATE DTP01 DTP02 REF VALUE(S) C2 NM101 NM102 NM103 DTP DHS Encounter Data REQ 573 D8 DATE CLAIM PAID DATE EXPRESSED IN CCYYMMDD F8 ADJUDICATION OR PAYMENT DATE MUST BE USED FOR MEDICARE CLAIMS. ORIGINAL REFERENCE NUMBER Y C1 Y Y Y Y Y Y Y MEDICARE ICN BEGIN WITH 1 AND INCREMENT BY 1. HC HCPCS/CPT CODE 18 837P HIPAA Implementation Guide Data LOOP SEGMENT NAME ID REQ SV1012 SV1013 SV1014 SV1015 SV1016 PRODUCT/SERVICE ID Y HCPCS/CPT PROCEDURE CODE PROCEDURE MODIFIER C1 MODIFIER 1 PROCEDURE MODIFIER C1 MODIFIER 2 PROCEDURE MODIFIER C1 MODIFIER 3 PROCEDURE MODIFIER C1 MODIFIER 4 SV1017 DESCRIPTION C1 SV102 MONETARY AMOUNT Y DESCRIPTION OF NON SPECIFIC, (NOC), UNLISTED, UNCLASSIFIED OR MISCELLANEOUS CODES WHEN REPORTED IN SV101-2. YOU SHOULD ALSO REPORT THE HEARING AID MODEL NUMBER IN THIS DATA ELEMENT (NOT IN THE L2300/K3 SEGMENT). LINE ITEM CHARGE AMOUNT. PER APPENDIX A IN THE IMPLEMENTATION GUIDE, DECIMAL DATA ELEMENTS IN DATA ELEMENT 782 WILL BE LIMITED TO A MAXIMUM LENGTH OF 10 CHARACTERS INCLUDING REPORTED OR IMPLIED PLACES FOR CENTS. SV103 UNIT/BASIS OF MEASUREMENT CODE Y SV104 SV105 QUANTITY FACILITY CODE VALUE Y C1 SV107 COMP. DIAGNOSIS CODE POINTER DIAGNOSIS CODE POINTER Y DIAGNOSIS CODE POINTER C1 DIAGNOSIS CODE POINTER C1 SV1071 SV1072 SV1073 Minnesota Department of Human Services DHS Encounter Data ELEMENT NAME Y VALUE(S) DHS REQUIREMENT DESCRIPTION UN UNITS MJ MINUTES-USED FOR ANESTHESIA CLAIMS UNITS OF SERVICE OVERRIDE CLM05-1 IN LOOP 2300 WHEN PLACE OF SERVICE IS DIFFERENT THAN THE VALUE SENT AT THE CLAIM LEVEL. POINTER TO RELATED DIAGNOSIS CODE POINTER TO RELATED DIAGNOSIS CODE POINTER TO RELATED DIAGNOSIS CODE 19 837P HIPAA Implementation Guide Data LOOP SEGMENT DTP NAME ID REQ SV1074 SV109 DIAGNOSIS CODE POINTER C1 YES/NO CONDITION OR RESPONSE CODE DTP01 DTP02 DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER DATE – SERVICE DATE DTP03 DTP QTY REF DATE TIME PERIOD CERTIFICATION REVISION DATE DTP01 DTP02 DTP03 RECERTIFICATION DATE QTY01 QTY02 QUANTITY QUALIFIER QUANTITY AMBULANCE PATIENT COUNT REPRICED LINE ITEM REFERENCE NUMBER DHS REQUIREMENT DESCRIPTION C1 Y POINTER TO RELATED DIAGNOSIS CODE EMERGENCY RELATED Y Y Y 472 D8 SERVICE DATE(S) DATE EXPRESSED IN CCYYMMDD RD8 DATE EXPRESSED IN CCYYMMDDCCYYMMDD SERVICE DATE(S) Y Y Y Y C2 Y Y 607 D8 MCO PAID DATE PAID DATE DATE EXPRESSED IN CCYYMMDD DATE OF PAYMENT TO PROVIDER FOR PHYSICIAN ADMINISTERED DRUGS. PT PATIENTS AMBULANCE PATIENT COUNT. REQUIRED WHEN MORE THAN ONE PATIENT IS TRANSPORTED IN THE SAME VEHICLE FOR AMBULANCE OR NON-EMERGENCY TRANSPORTATION SERVICES. 9B ALLOWED AMOUNT C2 REF02 REFERENCE IDENTIFICATION QUALIFIER MONETARY AMOUNT ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER Y Y ALLOWED AMOUNT IS THE PROVIDER CONTRACTED RATE PRIOR TO ANY EXCLUSIONS OR ADD-ONS. SEE APPENDIX – P. 77 C2 REF01 Minnesota Department of Human Services VALUE(S) C2 REF01 REF DHS Encounter Data ELEMENT NAME REFERENCE IDENTIFICATION QUALIFER Y 9D PAID AMOUNT 20 837P HIPAA Implementation Guide Data LOOP SEGMENT NAME ID REF02 2410 REQ MONETARY AMOUNT Y DRUG IDENTIFICATION LIN 2420A ITEM IDENTIFICATION LIN03 CTP04 QUANTITY C2 Y CTP05 COMPOSITE UNIT OF MEASURE Y CTP051 UNIT OR BASIS OF MEASUREMENT CODE Y DRUG PRICING THE AMOUNT PAID TO THE PROVIDER EXCLUDING THIRD PARTY LIABILITY, PROVIDER WITHHOLDS AND INCENTIVES, AND MEMBER COST SHARING. SEE APPENDIX – P. 77 USED WHEN PROC CODE MATCHES ONE ON LIST: HCPCS REQUIRING NDC Y N4 Y NATIONAL DRUG CODE NDC CODE FOR PHYSICIAN ADMINISTERED DRUGS. F2 DRUG QUANTITY FOR PHYSICIAN ADMINISTERED DRUGS. UNIT OR BASIS FOR MEASUREMENT CODE INTERNATIONAL UNIT GR GRAM ME MILLIGRAM ML MILLILITER UN UNIT C1 OVERRIDE 2310B LOOP IF THE RENDERING PROVIDER ON A LINE ITEM IS DIFFERENT THAN THE NUMBER SUBMITTED AT THE CLAIM LEVEL. RENDERING PROVIDER NAME NM101 NM102 ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER Y Y NM103 NAME LAST OR ORGANIZATION NAME NAME FIRST Y RENDERING PROVIDER NAME C1 IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE Y ANY TEXT- REQUIRED IF “1” IS SENT IN NM102. NPI NM104 NM108 NM109 REF DHS REQUIREMENT DESCRIPTION C2 PRODUCT/SERVICE ID QUALIFIER PRODUCT SERVICE ID RENDERING PROVIDER NAME NM1 VALUE(S) C2 LIN02 CTP DHS Encounter Data ELEMENT NAME REFERENCE IDENTIFICATION Minnesota Department of Human Services Y C1 82 1 2 XX RENDERING PROVIDER PERSON NON-PERSON RENDERING PROVIDER NPI 21 837P HIPAA Implementation Guide Data LOOP SEGMENT 2430 NAME ID REQ VALUE(S) DHS REQUIREMENT DESCRIPTION REF01 REFERENCE IDENTIFICATION QUALIFIER Y G2 PROVIDER COMMERCIAL NUMBER REF02 REFERENCE IDENTIFICATION Y C2 LINE ADJUDICATION INFORMATION SVD LINE ADJUDICATION INFORMATION OTHER PAYER PRIMARY IDENTIFIER DHS UMPI NUMBER ASSIGNED TO THE MANAGED CARE ORGANIZATION DOLLAR AMOUNT OF ALL TPL AND/OR MEDICARE PAYMENT INFORMATION. SVD01 IDENTIFICATION CODE Y SVD02 MONETARY AMOUNT Y SVD03 COMPOSITE MEDICAL PROCEDURE PRODUCT/SERVICE ID QUALIFIER PRODUCT SERVICE ID Y Y HCPCS PROCEDURE CODE PROCEDURE MODIFIER C1 MODIFIER 1 PROCEDURE MODIFIER C1 MODIFIER 2 PROCEDURE MODIFIER C1 MODIFIER 3 PROCEDURE MODIFIER C1 MODIFIER 4 QUANTITY Y C1 Y UNITS OF SERVICE LINE ADJUSTMENT CAS01 Minnesota Department of Human Services DHS UMPI NUMBER. THIS LOOP IS REQUIRED ONLY WHEN THERE ARE PHYSICIAN ADMINISTERED DRUGS AND THIRD PARTY LIABILITY ON THE CLAIM. IT IS REQUIRED SO THAT LINE LEVEL TPL CAN BE SUBMITTED FOR THE DRUGS. THIS LOOP IS REQUIRED – MCO ADJUDICATION INFORMATION AS A PAYER IS SUBMITTED HERE AND TPL ADJUDICATION INFORMATION, INCLUDING PHYSICIAN ADMINISTERED DRUGS. UP TO 15 OF THIS LOOP CAN BE SENT; SEND ONE PER L2330B/NM1*PR SEGMENT. Y SVD031 SVD032 SVD033 SVD034 SVD035 SVD036 SVD05 CAS DHS Encounter Data ELEMENT NAME CLAIM ADJUSTMENT GROUP CODE Y HC CO HCPCS CODE CONTRACTUAL OBLIGATIONS 22 837P HIPAA Implementation Guide Data LOOP SEGMENT NAME ID CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19 DTP TRL SE CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY DATE OR TIME OR PERIOD DTP01 DTP02 AMT ELEMENT NAME DTP03 DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD AMT01 AMT02 AMOUNT QUALIFIER CODE MONETARY AMOUNT SE01 NUMBER OF INCLUDED SEGMENTS REMAINING PATIENT LIABILITY TRAILER TRANSACTION SET TRAILER Minnesota Department of Human Services DHS Encounter Data REQ VALUE(S) DHS REQUIREMENT DESCRIPTION CR OA PI PR Y CORRECTION AND REVERSALS OTHER ADJUSTMENTS PAYOR INITIATED REDUCTIONS PATIENT RESPONSIBILITY ADJUSTMENT REASON CODE Y C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE Y C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE Y C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE Y C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE Y C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE Y C1 Y C2 Y Y ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY MEDICARE OR PAYER PAID DATE 573 D8 DATE CLAIM PAID DATE EXPRESSED IN FORMAT CCYYMMDD ENTER ADJUDICATION DATE EAF AMOUNT OWED REMAINING PATIENT LIABILITY Y C1 Y Y Y Y TOTAL SEGMENTS IN TRANSACTION SET. 23 837P HIPAA Implementation Guide Data LOOP SEGMENT NAME ID SE02 Minnesota Department of Human Services DHS Encounter Data ELEMENT NAME REQ TRANSACTION SET CONTROL NUMBER Y VALUE(S) DHS REQUIREMENT DESCRIPTION MUST MATCH ST02. 24 ENVELOPE INFORMATION INTERCHANGE CONTROL HEADER REFERENCE DESCRIPTION ISA01 ELEMENT DESCRIPTION 837P VALUES DO NOT SEND SEGMENT DELIMITERS THAT ARE MORE THAN ONE BYTE. SEE APPENDIX A.1.2.4 THROUGH A.1.2.7 IN THE 837 IMPLEMENTATION GUIDE FOR LISTS OF CHARACTERS THAT ARE ALLOWED. IF YOU SEND CHARACTERS THAT ARE NOT WITHIN THE SETS SHOWN IN THE GUIDE, YOUR FILE WILL NOT BE PROCESSED. QUALIFIER VALUES ARE CASE SENSITIVE. IF LOWER CASE VALUES ARE SENT, YOUR FILE WILL NOT BE PROCESSED. PLEASE SEND ONE INTERCHANGE PER FILE UNTIL FURTHER NOTICE. IF YOU SEND MORE THAN ONE INTERCHANGE, THE ADDITIONAL INTERCHANGES MAY NOT BE PROCESSED. 00-NO AUTHORIZATION INFORMATION PRESENT. ISA02 ISA03 AUTHORIZATION INFORMATION QUALIFIER AUTHORIZATION INFORMATION SECURITY INFORMATION QUALIFIER ISA04 ISA05 ISA06 SECURITY INFORMATION INTERCHANGE ID QUALIFIER INTERCHANGE SENDER ID ISA07 ISA08 INTERCHANGE ID QUALIFIER INTERCHANGE RECEIVER ID ISA09 INTERCHANGE DATE 10 SPACES ZZ-MUTUALLY DEFINED THIS NUMBER MUST BE THE ONE USED TO REGISTER IN THE MN-ITS SYSTEM AND MUST CORRESPOND TO THE MN-ITS MAILBOX NUMBER. THIS MUST CHANGE TO THE 10-DIGIT NATIONAL PROVIDER IDENTIFIER (NPI) OR UNIVERSAL MINNESOTA PROVIDER IDENTIFIER (UMPI) FOLLOWED BY 5 TRAILING SPACES. 30-U.S. FEDERAL TAX IDENTIFICATION NUMBER 41-1674742-MN DEPT OF HUMAN SERVICES FEIN FOLLOWED BY 5 TRAILING SPACES. THIS NUMBER MUST CONTAIN A HYPHEN. CURRENT DATE FORMATTED AS 6-DIGITS (YYMMDD) ISA10 ISA11 INTERCHANGE TIME REPETITION SEPARATOR CURRENT TIME FORMATTED AS 4-DIGITS(HHMM) PLEASE SEND DHS “[“ ISA12 00501-DRAFT STANDARDS FOR TRIAL USE APPROVED ASC X-12 REVIEW BOARD ISA13 INTERCHANGE CONTROL VERSION NUMBER INTERCHANGE CONTROL NUMBER ISA14 ISA15 ISA16 ACKNOWLEDGMENT REQUESTED USAGE INDICATOR COMPONENT ELEMENT SEPARATOR PROVIDER OPTION 0-NO OR 1-YES. SEND P-PRODUCTION DATE FOR PRODUCTION FILES AND T-TEST DATA FOR TEST FILES. PROVIDER OPTION/SUB-ELEMENT DELIMITER. Minnesota Department of Human Services 10 SPACES 00-NO SECURITY INFORMATION PRESENT BEGIN WITH "1" 9-DIGIT ZERO FILLED LEFT TO RIGHT. ALL ZEROS IS NOT AN ALLOWED VALUE. 25 INTERCHANGE CONTROL TRAILER REFERENCE DESCRIPTION IEA01 IEA02 ELEMENT DESCRIPTION NUMBER OF INCLUDED FUNCTIONAL GROUPS INTERCHANGE CONTROL NUMBER 837P VALUES PROVIDER TRANSLATOR COUNTS NUMBER OF FUNCTIONAL GROUPS WITHIN THE INTERCHANGE. SAME AS ISA13 FUNCTIONAL GROUP HEADER REFERENCE DESCRIPTION GS01 GS02 ELEMENT DESCRIPTION FUNCTIONAL IDENTIFIER CODE APPLICATION SENDER’S CODE GS03 GS04 GS05 APPLICATION RECEIVER’S CODE FUNCTIONAL GROUP CREATION DATE CREATION TIME GS06 GROUP CONTROL NUMBER GS07 GS08 RESPONSIBLE AGENCY CODE VERSION/RELEASE/INDUSTRY IDENTIFIER CODE 837P VALUES HC-HEALTH CARE CLAIMS (837) THIS MUST CHANGE TO 10-DIGIT NATIONAL PROVIDER IDENTIFIOER OR UNIVERSAL MINNESOTA PROVIDER IDENTIFIER (UMPI). MUST MATCH THE NUMBER IN ISA06 WITHOUT THE TRAILING SPACES. 41-1674742-MN DEPT OF HUMAN SERVICES FEIN. THIS NUMBER MUST CONTAIN A HYPHEN. CURRENT DATE FORMATTED AS 8-DIGITS (CCYYMMDD). CURRENT TIME FORMATTED AS 4-DIGITS (HHMM). UNIQUE 1-DIGIT TO 9-DIGIT NUMBER. PREFERABLY START AT 1 AND INCREMENT BY 1 FOR EACH SUCCESSIVE FUNCTIONAL GROUP FROM SENDER TO RECEIVER, AND NOT RESET TO STARTING VALUE OF 1 WITHIN EACH INTERCHANGE OR EACH DAY. X-ACCREDITED STANDARDS COMMITTEE X-12 005010X222A1DRAFT STANDARDS APPROVED BY ASC X12 BOARD. FUNCTIONAL GROUP TRAILER REFERENCE DESCRIPTION GE01 GE02 ELEMENT DESCRIPTION NUMBER OF TRANSACTION SETS INCLUDED GROUP CONTROL NUMBER Minnesota Department of Human Services 837P VALUES 1 - 6 DIGITS. PROVIDER TRANSLATOR COUNTS NUMBER OF TRANSACTION SETS WITHIN THE FUNCTIONAL GROUP. MUST MATCH GS06 NUMBER. 26 3 INSTITUTIONAL DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP HDR SEG ST NAME HEADER TRANSACTION SET HEADER ID ST01 ST02 ST03 BHT TRANSACTION SET IDENTIFIER CODE TRANSACTION SET CONTROL NUMBER IMPLEMENTATION CONVENTION REFERENCE BEGIN OF HIERARCHICAL TXN BHT01 BHT02 1000A ELEMENT NAME HIERARCHICAL STRUCTURE CODE TRANSACTION SET PURPOSE CODE BHT03 BHT04 BHT05 BHT06 REFERENCE IDENTIFICATION DATE TIME TRANSACTION TYPE CODE NM101 NM102 NM103 ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME IDENTIFICATION CODE QUALIFIER SUBMITTER NAME NM1 SUBMITTER NAME NM108 PER NM109 IDENTIFICATION CODE PER01 PER02 PER03 CONTACT FUNCTION CODE NAME COMMUNICATION NUMBER QUALIFIER COMMUNICATION NUMBER SUBMITTER EDI CONTACT INFO PER04 Minnesota Department of Human Services REQ Y Y Y VALUE DESCRIPTION 837 HEALTH CARE CLAIM Y Y MCO SYSTEM GENERATED NUMBER 005010 X223A2 837I VERSION NUMBER Y Y 0019 Y 00 INFORMATION SOURCE, SUBSCRIBER DEPENDENT ORIGINAL Y Y Y Y Y Y 18 RP REISSUE SUBMISSION NUMBER-MCO ASSIGNED TRANSACTION SET CREATION DATE TRANSACTION SET CREATION TIME REPORTING THIS LOOP IS USED FOR INFORMATION REGARDING THE MCO RESPONSIBLE FOR THE ENCOUNTER. Y Y Y Y 41 2 SUBMITTER NON-PERSON ENTITY MCO (OR CONTRACTOR) NAME Y 46 TRADING PARTNER ID Y Y Y Y Y Y MCO UMPI NUMBER IC TE INFORMATION CONTACT MCO SUBMITTER CONTACT TELEPHONE MCO CONTACT PHONE NUMBER 27 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP 1000B SEG NM1 NAME RECEIVER NAME RECEIVER NAME ID NM101 NM102 NM103 NM108 NM109 2000A HL NM1 HIERARCHICAL ID NUMBER HIERARCHICAL LEVEL CODE HIERARCHICAL CHILD CODE BILLING PROVIDER SPECIALTY INFORMATION Minnesota Department of Human Services DESCRIPTION 40 2 RECEIVER NON-PERSON ENTITY MN DEPT OF HUMAN SERVICES Y 46 TRADING PARTNER ID Y 411674 742 RECEIVER ID Y Y Y Y 20 1 PRV03 PROVIDER CODE REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION NM101 ENTITY IDENTIFIER CODE NM102 NM103 ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME Y Y 2 NM108 IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE C1 XX BILLING PROVIDER NAME BILLING PROVIDER NAME BILLING PROVIDER ADDRESS VALUE 1 THEN INCREMENT BY 1. INFORMATION SOURCE ADDITIONAL SUBORDINATE HL DATA SEGMENT IN THIS HIERARCHICAL STRUCTURE C1 NM109 N3 REQ Y Y Y Y Y Y PRV01 PRV02 2010AA ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL HIERARCHICAL LEVEL HL01 HL03 HL04 PRV ELEMENT NAME Y Y BI PXC Y Y Y Y BILLING HEALTH CARE PROVIDER TAXONOMY CODE PROVIDER TAXONOMY CODE 85 BILLING PROVIDER Correction of QUALIFIER DESCRIPTION based on review of X12 implementation guide. PAY TO PROVIDER NON-PERSON ENTITY DEFAULT TO ANY TEXT NOT USED BUT REQUIRED BY STANDARD BILLING PROVIDER ORGANIZATIONAL NAME CMS NATIONAL PROVIDER IDENTIFIER (NPI) NATIONAL PROVIDER IDENTIFIER (NPI) C1 Y 28 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG N4 REF NAME ID N301 ELEMENT NAME ADDRESS INFORMATION REQ Y N302 ADDRESS INFORMATION C1 Y N401 CITY NAME Y N402 STATE OR PROVINCE CODE C1 N403 POSTAL CODE C1 BILLING PROVIDERCITY/STATE/ZIP BILLING/PAY TO PROVIDER TAX IDENTIFICATION HL SBR NM1 Y REFERENCE IDENTIFICATION Y Y SUBSCRIBER HIERARCHICAL LEVEL HIERARCHICAL LEVEL EMPLOYER IDENTIFICATION NUMBER OR DEFAULT TO ANY NUMBER REQUIRED BY STANDARD ID NUMBER HIERARCHICAL ID NUMBER Y Y HL02 HIERARCHICAL PARENT ID Y HL03 HL04 HIERARCHICAL LEVEL CODE HIERARCHICAL CHILD CODE Y Y 22 0 SBR01 Y Y U UNKNOWN Y 18 SELF SBR09 PAYER RESPONSIBILITY SEQUENCE NUMBER CODE INDIVIDUAL RELATIONSHIP CODE CLAIM FILE INDICATOR CODE MC MEDICAID NM101 ENTITY IDENTIFIER CODE Y Y Y Y IL INSURED OR SUBSCRIBER SUBSCRIBER INFORMATION SUBSCRIBER NAME SUBSCRIBER NAME Minnesota Department of Human Services EI HL01 SBR02 2010BA REFERENCE IDENTIFICATION QUALIFIER DESCRIPTION DEFAULT TO ANY TEXT NOT USED BUT REQUIRED BY STANDARD BILLING PROVIDER ADDRESS LINE BILLING PROVIDER ADDRESS LINE “ANY TEXT” BILLING PROVIDER CITY NAME MN BILLING PROVIDER STATE OR PROVINCE CODE ANY ZIP CODE BILLING PROVIDER POSTAL ZONE OR ZIP CODE BILLING PROVIDER TAX IDENTIFICATION Y REF01 2000B VALUE START WITH 2 AND INCREMENT BY 1. 1 FOR FIRST ITERATION. CHANGES TO PROVIDER HL01 VALUE WHEN PROVIDER NUMBER CHANGES IN A TRANSACTION SET. SUBSCRIBER NO SUBORDINATE HL SEGMENT IN THIS HIERARCHICAL STRUCTURE 29 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG NAME ID NM102 NM103 NM104 NM105 NM108 2010BA ELEMENT NAME ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME NAME FIRST NM109 NAME MIDDLE IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE N301 ADDRESS INFORMATION SUBSCRIBER ADDRESS N3 2010BA N4 DMG REF SUBSCRIBER ADDRESS N401 SUBSCRIBER CITY Y N402 SUBSCRIBER STATE Y N403 SUBSCRIBER ZIP CODE DMG0 1 DMG0 2 DMG0 3 DATE TIME FORMAT QUALIFIER DATE TIME PERIOD Y Y Y GENDER CODE PROPERTY AND CASUALTY CLAIM NUMBER PAYER NAME PAYER NAME Minnesota Department of Human Services MI DEFAULT TO ANY TEXT – NOT USED BUT REQUIRED BY STANDARD. SINCE THE PATIENT IS ALWAYS THE SUBSCRIBER UNDER MHCP, THIS SEGMENT IS REQUIRED. DEFAULT TO ANY TEXT – NOT USED BUT REQUIRED BY STANDARD DEFAULT TO ANY TEXT – NOT USED BUT REQUIRED BY STANDARD DEFAULT TO “00000” D8 Y Y MEMBER MIDDLE INITIAL, IF KNOWN MEMBER ID NUMBER DHS ASSIGNED EIGHT DIGIT MEMBER ID SINCE THE PATIENT IS ALWAYS THE SUBSCRIBER UNDER MHCP, THIS SEGMENT IS REQUIRED. C1 Y Y DESCRIPTION PERSON MEMBER LAST NAME MEMBER FIRST NAME Y C2 SUBSCRIBER CITY, STATE, ZIP CODE DATE EXPRESSED IN CCYYMMDD SUBSCRIBER BIRTH DATE U UNKNOWN (DEFAULT) F M FEMALE MALE Y4 AGENCY CLAIM NUMBER C2 REF02 NM1 C1 Y C2 SUBSCRIBER DEMOGRAPHICS VALUE 1 C1 SUBSCRIBER CITY/STATE/ZIP REF01 2010BB REQ Y Y REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION Y Y Y y MCO’S OWN MEMBER NUMBER 30 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG NAME ID NM101 NM102 NM103 NM108 NM109 REF 2300 CLM ELEMENT NAME ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE BILLING PROVIDER SECONDARY IDENTIFICATION REF01 REFERENCE IDENTIFICATION QUALIFIER REF02 REFERENCE IDENTIFICATION CLM01 CLAIM SUBMITTER’S IDENTIFIER MONETARY AMOUNT CLAIM INFORMATION CLAIM INFORMATION CLM02 CLM05 CLM05 -1 CLM05 -2 CLM05 -3 REQ Y Y Y VALUE PR 2 DESCRIPTION PAYER NON-PERSON ENTITY MN DEPT OF HUMAN SERVICES Y PI PAYER ID Y 411674 742 DHS PAYER ID G2 (REPLACES 2010AA PAY TO PROVIDER UMPI) PROVIDER COMMERCIAL NUMBER UMPI OF BILLING PAY TO PROVIDER C1 Y Y Y Y Y MCO’S OWN CLAIM NUMBER (ICN) Y TOTAL CLAIM CHARGE AMOUNT (BILLED AMOUNT) PER APPENDIX A IN THE IMPLEMENTATION GUIDE, DECIMAL DATA ELEMENTS IN DATA ELEMENT 782 WILL BE LIMITED TO A MAXIMUM LENGTH OF 10 CHARACTERS INCLUDING REPORTED OR IMPLIED PLACES FOR CENTS. MUST BE GREATER THAN OR EQUAL TO ZERO HEALTH CARE SERVICE LOCATION INFORMATION FACILITY CODE VALUE Y FACILITY CODE VALUE Y FIRST TWO DIGITS OF THE TYPE OF BILL FACILITY CODE QUALIFIER Y CLAIM FREQUENCY TYPE CODE Y A 1 Minnesota Department of Human Services UNIFORM BILLING CLAIM FORM BILL TYPE CLAIM FREQUENCY TYPE CODE, CODE SPECIFYING THE FREQUENCY OF THE CLAIM; THIS IS THE THIRD POSITION OF THE UNIFORM BILLING CLAIM FORM BILL TYPE CODE SOURCE 235 ADMIT THRU DISCHARGE 31 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG NAME ID ELEMENT NAME REQ CLM06 YES/NO CONDITION OR RESPONSE CODE (PROVIDER SIGNATURE ON FILE) N/U CLM07 PROVIDER ACCEPT ASSIGNMENT CODE C1 CLM08 CLM09 YES/NO CONDITION OR RESPONSE CODE RELEASE OF INFORMATION CODE Y Y VALUE 2 DESCRIPTION INTERIM-FIRST CLAIM 3 INTERIM-CONTINUING CLAIM 4 INTERIM-LAST CLAIM 5 LATE CHARGES 7 8 REPLACEMENT VOID THIS DATA ELEMENT IS NO LONGER USED. N A NO ASSIGNED (DEFAULT) B C ACCEPTS ASSIGNMENT ON CLINICAL LAB SERVICES ONLY NOT ASSIGNED Y YES (DEFAULT) N NO W NOT APPLICABLE (USE W FOR PATIENT REFUSAL) YES, PROVIDER HAS A SIGNED STATEMENT PERMITTING RELEASE OF MEDICAL BILLING DATA RELATED TO A CLAIM (DEFAULT) INFORMED CONSENT TO RELEASE MEDICAL INFORMATION FOR CONDITIONS OR DIAGNOSES REGULATED BY FEDERAL STATUTES. Y I DTP DISCHARGE HOUR C1 Y DTP01 DATE/TIME QUALIFIER Y 096 DISCHARGE DTP02 DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD Y TM TIME EXPRESSED IN FORMAT HHMM DTP03 Minnesota Department of Human Services Y DISCHARGE TIME VALUE CAN BE DEFAULTED TO 00. 32 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG DTP DTP NAME STATEMENT DATES ID DTP01 DTP02 DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER DTP03 DATE TIME PERIOD DTP01 DTP02 DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD ADMISSION DATE/HOUR DTP03 CL1 INSTITUTIONAL CLAIM CODE CL101 CL102 CL103 AMT REF ELEMENT NAME PRIORITY (TYPE) OF ADMISSION OR VISIT POINT OF ORIGIN FOR ADMISSION OR VISIT PATIENT STATUS PATIENT ESTIMATED AMOUNT DUE PAYER CLAIM CONTROL NUMBER Minnesota Department of Human Services REQ Y C1 Y Y Y C1 Y Y VALUE DESCRIPTION 434 RD8 STATEMENT DATE EXPRESSED IN CCYYMMDDCCYYMMDD. WHEN THE STATEMENT IS FOR A SINGLE DATE OF SERVICE, THE FROM AND THROUGH DATE ARE THE SAME. STATEMENT FROM AND TO 435 DT ADMISSION DATE AND TIME EXPRESSED IN FORMAT CCYYMMDDHHMM ADMISSION DATE AND HOUR Y Y Y ADMISSION TYPE REQUIRED FOR ALL INPATIENT AND OUTPATIENT SERVICES ADMISSION SOURCE REQUIRED FOR ALL INPATIENT AND OUTPATIENT SERVICES PATIENT STATUS CODE LIST 239 C1: Follow HIPPA guide for all claims except CD residential C2: Required for CD residential treatment claims ALL TPL AND/OR MEDICARE PAYMENT INFORMATION IS SENT IN THIS SEGMENT WHETHER THE PAYMENT IS FROM THE PATIENT OR THE PROVIDER. C1 Y C1 AMT01 AMOUNT CODE QUALIFIER Y AMT02 MONETARY AMOUNT Y F3 PATIENT RESPONSIBILITY IF APPLICABLE ENTER TOTAL TPL AND/OR MEDICARE PAYMENT, IF APPLICABLE. PER APPENDIX A IN THE IMPLEMENTATION GUIDE, DECIMAL DATA ELEMENTS IN DATA ELEMENT 782 WILL BE LIMITED TO A MAXIMUM LENGTH OF 10 CHARACTERS INCLUDING REPORTED OR IMPLIED PLACES FOR CENTS. C1 33 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG NAME ID REF01 REF02 REF REPRICED CLAIM REFERENCE NUMBER REF02 REFERENCE IDENTIFICATION QUALIFIER REFERENCE INFORMATION EPSDT REFERRAL CRC01 CRC02 CRC03 CODE QUALIFIER CERTIFICATION CONDITION CODE APPLIES INDICATOR CONDITION INDICATOR PRINCIPAL DIAGNOSIS HI01 Minnesota Department of Human Services VALUE F8 DESCRIPTION ORIGINAL REFERENCE NUMBER 9A MCO’S ORIGINAL CLAIM (ICN) NUMBER. USED WHEN CLM05-3 IS 7REPLACEMENT OR 8-VOID. THIS IS FOR REPLACEMENT CLAIM OR VOID CLAIM USAGE ONLY. REQUIRED FIELD, THIS SEGMENT IS USED FOR INPATIENT & OUTPATIENT CLAIMS SEE APPENDIX – P. 77 ALLOWED AMOUNT 9C THE ALLOWED AMOUNT IS THE PROVIDER CONTRACTED RATE PRIOR TO ANY EXCLUSIONS OR ADD-ONS. SEE APPENDIX – P. 77 REQUIRED FIELD, THIS SEGMENT IS USED FOR INPATIENT & OUTPATIENT CLAIMS SEE APPENDIX – P. 77 PAID AMOUNT ZZ PAID AMOUNT IS THE AMOUNT PAID TO THE PROVIDER EXCLUDING THIRD PARTY LIABILITY, PROVIDER WITHHOLDS, INCENTIVES, AND MEMBER COST SHARING. SEE APPENDIX – P. 77 C&TC REFERRAL MUTUALLY DEFINED N Y NO YES AV NU S2 ST AVAILABLE-NOT USED/ PATIENT REFUSED REFERRAL NOT USED UNDER TREATMENT NEW SERVICES REQUESTED ABK ICD-10-CM PRINCIPAL DIAGNOSIS CODE C1 C2 Y C2 REF02 HI REFERENCE IDENTIFICATION QUALIFIER REFERENCE INFORMATION ADJUSTED REPRICED CLAIM NUMBER REF01 CRC REQ C1 C2 REF01 REF ELEMENT NAME REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION HEALTH CARE CODE INFORMATION C2 Y C1 Y Y Y Y 34 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG HI NAME ID ELEMENT NAME REQ HI01-2 PRINCIPAL DIAGNOSIS CODE Y HI01-9 PRESENT ON ADMISSION INDICATOR C1 ADMITTING DIAGNOSIS HI01-2 CODE LIST QUALIFIER PRESENT ON ADMISSION INDICATOR N NO U UNKNOWN W NOT APPLICABLE Y YES C1 ABJ ICD-10-CM ADMITTING DIAGNOSIS CODE BJ ICD-9-CM ADMITTING DIAGNOSIS CODE APR ICD-10-CM PATIENTS REASON FOR VISIT CODE ICD-9-CM PATIENTS REASON FOR VISIT CODE PATIENT REASON FOR VISIT INDUSTRY CODE PATIENTS REASON FOR VISIT C1 HI01 HI01-1 HEALTH CARE CODE INFO CODE LIST QUALIFIER CODE Y Y PR HI01-2 INDUSTRY CODE Y HI02 THRU HI03 HI02-1 THRU HI1031 HEALTH CARE CODE INFO C1 CODE LIST QUALIFIER CODE Y APR PR HI02-2 THRU HI1032 HI INDUSTRY CODE EXTERNAL CAUSE OF INJURY Y Correction of REQ value based on review of X12 implementation guide. Only H101 is required if this HI segment is used. ICD-10-CM PATIENTS REASON FOR VISIT CODE ICD-9-CM PATIENTS REASON FOR VISIT CODE PATIENT REASON FOR VISIT C1 HI01 Minnesota Department of Human Services DESCRIPTION ICD-9-CM PRINCIPAL DIAGNOSIS CODE DO NOT SEND DECIMAL POINTS IN THE DIAGNOSIS CODE. C1 HI01-1 HI VALUE BK HEALTH CARE CODE INFORMATION Y 35 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG NAME ID HI01-1 ELEMENT NAME CODE LIST QUALIFIER CODE REQ Y VALUE ABN BN HI01-2 INDUSTRY CODE Y HI01-9 PRESENT ON ADMISSION INDICATOR C1 HI02 THRU HI12 HI02-1 THRU HI12-1 HI02-2 THRU HI12-2 HI02-9 THRU HI12-9 HI HEALTH CARE CODE INFORMATION C1 CODE LIST QUALIFIER CODE Y INDUSTRY CODE Y PRESENT ON ADMISSION INDICATOR C1 OTHER DIAGNOSIS INFORMATION Y HI01-1 HEALTH CARE CODE INFORMATION CODE LIST QUALIFIER CODE HI01-2 INDUSTRY CODE Y HI01-9 PRESENT ON ADMISSION INDICATOR C1 Y NO U UNKNOWN W NOT APPLICABLE Y YES ABN Correction of REQ value based on review of X12 implementation guide. Only H101 is required if this HI segment is used. ICD-10-CM EXTERNAL CAUSE OF INJURY CODE BN ICD-9-CM EXTERNAL CAUSE OF INJURY CODE EXTERNAL CAUSE OF INJURY CODE N NO U UNKNOWN W NOT APPLICABLE Y YES C1 HI01 Minnesota Department of Human Services N DESCRIPTION ICD-10-CM EXTERNAL CAUSE OF INJURY CODE ICD-9-CM EXTERNAL CAUSE OF INJURY CODE EXTERNAL CAUSE OF INJURY CODE DO NOT SEND DECIMAL POINTS IN THE DIAGNOSIS CODE. ABF ICD-10-CM OTHER DIAGNOSIS BF ICD-9-CM OTHER DIAGNOSIS OTHER DIAGNOSIS N NO U UNKNOWN 36 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG HI NAME ID ELEMENT NAME REQ HI02 THRU HI12 HI02-1 THRU HI12-1 HEALTH CARE CODE INFORMATION C1 CODE LIST QUALIFIER CODE Y HI02-2 THRU HI12-2 HI02-9 THRU HI12-9 INDUSTRY CODE Y PRESENT ON ADMISSION INDICATOR C1 PRINCIPAL PROCEDURE INFORMATION VALUE W Y ABF BF ICD-9-CM OTHER DIAGNOSIS OTHER DIAGNOSIS N NO U W Y UNKNOWN NOT APPLICABLE YES BBR ICD-10-PCS PRINCIPAL PROCEDURE CODE ICD-9- CM PRINCIPAL PROCEDURE PRINCIPAL PROCEDURE CODE DATE EXPRESSED IN FORMAT CCYYMMDD PRINCIPAL PROCEDURE DATE C1 HI01 Y HI01-1 HEALTH CARE CODE INFORMATION CODE LIST QUALIFIER HI01-2 HI01-3 INDUSTRY CODE DATE TIME PERIOD QUALIFIER Y C1 HI01-4 HI DATE TIME PERIOD C1 C1 HI01 Y HI01-1 HEALTH CARE CODE INFORMATION CODE LIST QUALIFIER CODE HI01-2 INDUSTRY CODE Y HI01-3 DATE TIME PERIOD FORMAT QUALIFIER Y Y BR HI OTHER PROCEDURE INFORMATION Minnesota Department of Human Services DESCRIPTION NOT APPLICABLE YES Correction of REQ value based on review of X12 implementation guide. Only H101 is required if this HI segment is used. ICD-10-CM OTHER DIAGNOSIS Y D8 BBQ ICD-10-PCS OTHER PROCEDURE CODE BQ ICD-9-CM PROCEDURE PROCEDURE CODE D8 DATE EXPRESSED IN FORMAT CCYYMMDD 37 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG HI NAME OCCURRENCE SPAN INFORMATION Minnesota Department of Human Services ID HI01-4 ELEMENT NAME DATE TIME PERIOD REQ Y VALUE HI02 THRU HI12 HI02-1 THRU HI12-1 HEALTH CARE CODE INFORMATION C1 CODE LIST QUALIFIER CODE Y HI02-2 THRU HI12-2 HI02-3 THRU HI12-3 HI02-4 THRU HI12-4 HI INDUSTRY CODE Y DATE TIME PERIOD FORMAT QUALIFIER Y DATE TIME PERIOD Y HI01 Y HI01-1 HEALTH CARE CODE INFORMATION CODE LIST QUALIFIER CODE HI01-2 INDUSTRY CODE Y HI01-3 DATE TIME PERIOD FORMAT QUALIFIER Y HI01-4 DATE TIME PERIOD Y OCCURRENCE SPAN CODE DATE HI02 THRU HI12 HI02-1 THRU HI12-1 HI02-2 THRU HI12-2 HEALTH CARE CODE INFORMATION C1 CODE LIST QUALIFIER CODE Y Correction of REQ value based on review of X12 implementation guide. Only H101 is required if this HI segment is used. OCCURRENCE SPAN INDUSTRY CODE Y BBQ DESCRIPTION PROCEDURE DATE Correction of REQ value based on review of X12 implementation guide. Only H101 is required if this HI segment is used. ICD-10-PCS OTHER PROCEDURE CODE BQ ICD-9-CM PROCEDURE PROCEDURE CODE D8 DATE EXPRESSED IN FORMAT CCYYMMDD PROCEDURE DATE C1 Y BI OCCURRENCE SPAN OCCURRENCE SPAN CODE RD8 BI RANGE OF DATES EXPRESSED IN FORMAT CCYYMMDD-CCYYMMDD OCCURRENCE SPAN CODE 38 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG HI NAME OCCURRENCE INFORMATION ID HI02-3 THRU HI12-3 HI02-4 THRU HI12-4 HI HI01 HI01-1 HI01-2 HI01-3 HI VALUE INFORMATION HI01-4 HI02 THRU HI12 HI02-1 THRU HI12-1 HI02-2 THRU HI12-2 HI02-3 THRU HI12-3 HI02-4 THRU HI12-4 HI HI01 ELEMENT NAME DATE TIME PERIOD FORMAT QUALIFIER REQ Y DATE TIME PERIOD Y HEALTH CARE CODE INFORMATION CODE LIST QUALIFIER CODE INDUSTRY CODE DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD HEALTH CARE CODE INFORMATION Y Y Y INDUSTRY CODE Y DATE TIME PERIOD FORMAT QUALIFIER Y DATE TIME PERIOD Y HI01-2 INDUSTRY CODE OCCURRENCE SPAN CODE DATE BH D8 Y C1 Y HI01-1 BH Minnesota Department of Human Services MONETARY AMOUNT OCCURRENCE OCCURRENCE CODE DATE EXPRESSED IN FORMAT CCYYMMDD OCCURRENCE CODE DATE Correction of REQ value based on review of X12 implementation guide. Only H101 is required if this HI segment is used. OCCURRENCE OCCURRENCE CODE D8 DATE EXPRESSED IN CCYYMMDD OCCURRENCE DATE C2 Y Y BE Y Y VALUE VALUE CODE 80 81 HI01-5 DESCRIPTION RANGE OF DATES EXPRESSED IN FORMAT CCYYMMDD-CCYYMMDD C1 Y CODE LIST QUALIFIER CODE HEALTH CARE CODE INFORMATION CODE LIST QUALIFIER CODE VALUE RD8 COVERED DAYS NON-COVERED DAYS VALUE CODE AMOUNT 39 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG HI NAME CONDITION INFORMATION ID HI02 THRU HI12 HI02-1 THRU HI12-1 HI02-2 THRU HI12-2 HI02-5 THRU HI12-5 HI HI01 HI01-1 HI01-2 HI02 THRU HI12 HI02-1 THRU HI12-1 HI02-2 THRU HI12-2 2310A ELEMENT NAME HEALTH CARE CODE INFORMATION REQ C2 VALUE CODE LIST QUALIFIER CODE Y BE INDUSTRY CODE Y COVERED DAYS NON-COVERED DAYS VALUE CODE AMOUNT Y Y C1 BG CODE LIST QUALIFIER CODE Y BG CONDITION CONDITION CODE Correction of REQ value based on review of X12 implementation guide. Only H101 is required if this HI segment is used. CONDITION INDUSTRY CODE Y MONETARY AMOUNT HEALTH CARE CODE INFORMATION CODE LIST QUALIFIER CODE INDUSTRY CODE HEALTH CARE CODE INFORMATION Y C1 Y CONDITION CODE C1 ATTENDING PHYSICIAN NAME Minnesota Department of Human Services VALUE CODE 80 81 ATTENDING PHYSICIAN NAME NM1 DESCRIPTION Correction of REQ value based on review of X12 implementation guide. Only H101 is required if this HI segment is used. VALUE C1 Y Y NM101 NM102 ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER NM103 ATTENDING PROVIDER LAST NAME Y NM104 ATTENDING PROVIDER FIRST NAME C1 71 1 2 ATTENDING PHYSICIAN PERSON NON-PERSON X12 implementation guide doesn’t support this qualifier. DEFAULT TO ANY TEXT – NOT USED BUT REQUIRED BY STANDARD DEFAULT TO ANY TEXT- REQUIRED IF “1” IS SENT IN NM102. 40 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG NAME ID NM108 NM109 REF ATTENDING PHYSICIAN SECONDARY IDENTIFICATION REF02 NM1 NM104 NM108 NM109 REF02 NM1 ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER OPERATING PHYSICIAN LAST NAME OPERATING PHYSICIAN FIRST NAME ID CODE QUALIFIER ID CODE REFERENCE IDENTIFICATION REF01 2310D REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION OPERATING PHYSICIAN NAME OPERATING PHYSICIAN NAME NM101 NM102 NM103 REF REQ Y Y REFERENCE IDENTIFICATION QUALIFIER OPERATING PHYSICIAN PRIMARY IDENTIFIER Y Y C1 C1 Y Y Y DESCRIPTION NPI ATTENDING PROVIDER PRIMARY IDENTIFIER - NPI NUMBER IF “XX” QUALIFIER IS ENTERED IN NM108. G2 PROVIDER COMMERCIAL NUMBER (FOR UMPI NUMBERS) DHS UMPI NUMBER. 72 1 OPERATING PHYSICIAN PERSON DEFAULT TO ANY TEXT – NOT USED BUT REQUIRED BY STANDARD DEFAULT TO ANY TEXT-NOT USED BUT REQUIRED IF “1” IS SENT IN NM102. NPI OPERATING PROVIDER NPI Y Y Y C21 Y XX G2 PROVIDER COMMERCIAL NUMBER (FOR UMPI NUMBERS) DHS UMPI NUMBER Y RENDERING PROVIDER NAME C1 RENDERING PROVIDER NAME C1 Minnesota Department of Human Services VALUE XX C2 REF01 2310B ELEMENT NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE NM101 ENTITY IDENTIFIER CODE Y 82 RENDERING PROVIDER NM102 ENTITY TYPE QUALIFIER Y 1 PERSON NM103 Y RENDERING PROVIDER LAST NAME NM104 NAME LAST OR ORGANIZATION NAME NAME FIRST C1 RENDERING PROVIDER FIRST NAME NM105 NAME MIDDLE C1 NM107 NAME SUFFIX C1 RENDERING PROVIDER MIDDLE NAME OR INITIAL RENDERING PROVIDER NAME SUFFIX NM108 IDENTIFICATION CODE QUALFIER Y XX NPI 41 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG REF NAME ID NM109 RENDERING PROVIDER SECONDARY IDENTIFICATION REF02 REFERENCE IDENTIFICATION QUALIFIER RENDERING PROVIDER SECONDARY IDENTIFIER SERVICE FACILITY LOCATION NAME NM1 REF DESCRIPTION RENDERING PROVIDER IDENTIFIER (NPI) Y G2 PROVIDER COMMERCIAL NUMBER Y RENDERING PROVIDER UMPI ID NUMBER C1 REQUIRED WHEN THE LOCATION OF HEALTH CARE SERVICE IS DIFFERENT THAN THAT CARRIED IN LOOP 2010AA NM101 ENTITY IDENTIFIER CODE Y 77 SERVICE LOCATION NM102 ENTITY TYPE QUALIFIER Y 2 NON-PERSON ENTITY NM103 NAME LAST OR ORGANIZATION NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE Y NM109 N4 VALUE SERVICE FACILITY LOCATION NAME NM108 N3 REQ Y C1 REF01 2310E ELEMENT NAME IDENTIFICATION CODE SERVICE FACILITY LOCATION ADDRESS XX C1 NPI LABORATORY OR FACILITY PRIMARY IDENTIFIER Y N301 ADDRESS INFORMATION Y N302 ADDRESS INFORMATION C1 SERVICE FACILITY LOCATION CITY, STATE, ZIP CODE LABORATORY OR FACILITY ADDRESS LINE LABORATORY OR FACILITY ADDRESS LINE Y N401 CITY NAME Y LABORATORY OR FACILITY CITY NAME N402 STATE OR PROVINCE CODE C1 N403 POSTAL CODE C1 LABORATORY OR FACILITY STATE OR PROVINCE CODE LABORATORY OR FACILITY POSTAL ZONE OR ZIP CODE SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION C1 REF01 REF02 Minnesota Department of Human Services C1 LABORATORY OR FACILITY NAME REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION Y Y G2 PROVIDER COMMERCIAL NUMBER (FOR UMPI NUMBERS) LABORATORY OR FACILITY SECONDARY IDENTIFIER (DHS UMPI NUMBER) 42 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP 2320 SEG NAME OTHER SUBSCRIBER INFORMATION SBR OTHER SUBSCRIBER INFORMATION ID SBR01 SBR02 ELEMENT NAME PAYER RESPONSIBILITY SEQUENCE NUMBER CODE INDIVIDUAL RELATIONSHIP CODE REQ C2 Y C1 Y Y VALUE P DESCRIPTION THIS LOOP IS REQUIRED ONLY WHEN THERE ARE PHYSICIAN ADMINISTERED DRUGS AND THIRD PARTY LIABILITY ON THE CLAIM. IT IS REQUIRED SO THAT LINE LEVEL TPL CAN BE SUBMITTED FOR THE DRUGS. THIS LOOP IS REQUIRED – THE FIRST OCCURRENCE MUST CONTAIN INFORMATION FOR THE MCO AS THE PRIMARY/SECONDARY PAYER. IF THE PRIMARY PAYER IS A THIRD PARTY, THE SECOND OCCURRENCE OF THIS SEGMENT SHOULD CONTAIN A “P” AND INFORMATION RELATED TO THE RELEVANT THIRD PARTY PAYER. UP TO 10 SBR LOOPS CAN BE SENT. Correction of REQ based on review of X12 implementation guide. PRIMARY S SECONDARY T TERTIARY SEE X12 IG FOR ADDT’L CODES /VALUE S 18 REFER TO THE IMPLEMENTATION GUIDE FOR THE OTHER CODES/VALUES TO USE. SEE X12 IG FOR ADDT’L CODES /VALUE S SBR03 Minnesota Department of Human Services REFERENCE IDENTIFICATION C1 SELF– this is the only option for the first occurrence. Subsequent occurrences should be billed as appropriate. REFER TO THE IMPLEMENTATION GUIDE FOR THE OTHER CODES/VALUES TO USE. INSURED GROUP OR POLICY NUMBER 43 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG NAME ID SBR04 ELEMENT NAME NAME REQ C1 VALUE DESCRIPTION OTHER INSURED GROUP NAME SBR09 CLAIM FILING INDICATOR CODE Y C1 HM 11 HEALTH MAINTENANCE ORGANIZATION (HM) – This is only for the first occurrence. On subsequent occurrences, fill out as appropriate. OTHER NON-FEDERAL PROGRAMS Correction of REQ value based on review of X12 implementation guide. REFER TO THE IMPLEMENTATION GUIDE FOR THE OTHER CODES/VALUES TO USE. SEE X12 IG FOR ADDT’L CODES /VALUE S CAS CLAIM LEVEL ADJUSTMENTS C1 CAS01 CAS02 Y CO CR CORRECTION AND REVERSALS OA OTHER ADJUSTMENTS PI PAYOR INITIATED REDUCTIONS PR PATIENT RESPONSIBILITY Y ADJUSTMENT REASON CODE CAS03 CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT Y ADJUSTMENT AMOUNT CAS04 QUANTITY C1 ADJUSTMENT QUANTITY CAS05 C1 ADJUSTMENT REASON CODE CAS06 CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT C1 ADJUSTMENT AMOUNT CAS07 QUANTITY C1 ADJUSTMENT QUANTITY CAS08 CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT C1 ADJUSTMENT REASON CODE C1 ADJUSTMENT AMOUNT CAS09 Minnesota Department of Human Services CLAIM ADJUSTMENT GROUP CODE COMPLETE IF YOU HAVE CLAIM LEVEL ADJUSTMENTS. YOU CAN ADD UP TO 5 CAS SEGMENTS. CONTRACTUAL OBLIGATIONS 44 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG AMT AMT AMT OI NAME ID CAS10 ELEMENT NAME QUANTITY REQ C1 CAS11 C1 ADJUSTMENT REASON CODE CAS12 CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT C1 ADJUSTMENT AMOUNT CAS13 QUANTITY C1 ADJUSTMENT QUANTITY CAS14 C1 ADJUSTMENT REASON CODE CAS15 CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT C1 ADJUSTMENT AMOUNT CAS16 QUANTITY C1 ADJUSTMENT QUANTITY CAS17 C1 ADJUSTMENT REASON CODE CAS18 CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT C1 ADJUSTMENT AMOUNT CAS19 QUANTITY C1 ADJUSTMENT QUANTITY COB PAYER PAID AMOUNT DESCRIPTION ADJUSTMENT QUANTITY C2 AMT01 AMOUNT QUALIFIER CODE Y AMT02 MONETARY AMOUNT Y REMAINING PATIENT LIABILITY D PAYOR AMOUNT PAID PAYER PAID AMOUNT “0” ( ZERO) IS AN ACCEPTABLE AMOUNT C1 AMT01 AMOUNT QUALIFIER CODE Y AMT02 MONETARY AMOUNT Y COB TOTAL NON-COVERED AMOUNT EAF AMOUNT OWED REMAINING PATIENT LIABILITY C1 AMT01 AMOUNT QUALIFIER CODE Y AMT02 MONETARY AMOUNT Y OTHER INSURANCE COVERAGE INFORMATION A8 NONCOVERED CHARGES – ACTUAL NON-COVERED CHARGE AMOUNT Y OI03 OI06 Minnesota Department of Human Services VALUE YES/NO CONDITION OR RESPONSE RELEASE OF INFORMATION Y Y Y Y BENEFITS ASSIGNMENT CERTIFICATION INDICATOR YES, PROVIDER HAS A SIGNED STATEMENT PERMITTING RELEASE OF MEDICAL BILLING DATA RELATED TO A CLAIM. 45 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP 2330A SEG NAME OTHER SUBSCRIBER NAME NM1 OTHER SUBSCRIBER NAME ID OTHER PAYER NAME Minnesota Department of Human Services REQ C2 VALUE DESCRIPTION THIS LOOP IS REQUIRED ONLY WHEN THERE ARE PHYSICIAN ADMINISTERED DRUGS AND THIRD PARTY LIABILITY ON THE CLAIM. IT IS REQUIRED SO THAT LINE LEVEL TPL CAN BE SUBMITTED FOR THE DRUGS. – MCO ADJUDICATION INFORMATION AS A PAYER IS SUBMITTER HERE AND TPL ADJUDICATION INFORMATION, INCLUDING PHYSICIAN ADMINISTERED DRUGS. ONE SUBSCRIBER NAME PER SBR SEGMENT. Y NM101 ENTITY ID CODE Y IL INSURED OR SUBSCRIBER NM102 ENTITY TYPE QUALIFIER Y 1 PERSON 2 NON-PERSON ENTITY UNKNO WN OTHER INSURED LAST NAME NM103 2330B ELEMENT NAME Y NM104 NAME LAST OR ORGANIZATION NAME NAME FIRST C1 OTHER INSURED FIRST NAME NM105 NAME MIDDLE C1 OTHER INSURED MIDDLE NAME NM107 NAME SUFFIX C1 OTHER INSURED NAME SUFFIX NM108 ID CODE QUALIFIER Y MI NM109 ID CODE Y UNKNO WN C2 MEMBER IDENTIFICATION NUMBER THIS LOOP IS REQUIRED ONLY WHEN THERE ARE PHYSICIAN ADMINISTERED DRUGS AND THIRD PARTY LIABILITY ON THE CLAIM. IT IS REQUIRED SO THAT LINE LEVEL TPL CAN BE SUBMITTED FOR THE DRUGS. – MCO ADJUDICATION INFORMATION AS A PAYER IS SUBMITTERED HERE AND TPL ADJUDICATION INFORMATION, INCLUDING PHYSICIAN ADMINISTERED DRUGS. ONE OTHER PAYER NAME PER SBR SEGMENT. 46 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG NM1 NAME OTHER PAYER NAME ID ELEMENT NAME REQ Y VALUE DESCRIPTION NM101 ENTITY IDENTIFIER CODE Y PR PAYER NM102 ENTITY TYPE QUALIFIER Y 2 NON-PERSON ENTITY NM103 NAME LAST OR ORGANIZATION NAME Y UNKNO WN OTHER PAYER LAST OR ORGANIZATION NAME NM108 IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE OTHER PAYER PRIMARY IDENTIFIER Y PI PAYOR IDENTIFICATION NM109 DTP CLAIM CHECK OR REMITTANCE DATE C1 DTP01 DATE/TIME QUALIFIER Y 573 DATE CLAIM PAID DTP02 DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD Y D8 DATE EXPRESSED IN CCYYMMDD DTP03 REF OTHER PAYER CLAIM CONTROL NUMBER REF01 REF02 2400 LX SERVICE LINE NUMBER SERVICE LINE NUMBER SV2 INSTITUTIONAL SERVICE LINE REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION LX01 ASSIGNED NUMBER SV201 SV202 PRODUCT/SERVICE ID COMPOSITE MEDICAL PROCEDURE IDENTIFIER PRODUCT/SERVICE ID QUALIFIER PRODUCT/SERVICE ID SV202 -1 SV202 -2 Minnesota Department of Human Services OTHER PAYER PRIMARY IDENTIFIER DHS UMPI NUMBER ASSIGNED TO THE MANAGED CARE ORGANIZATION Y Y ADJUDICATION OR PAYMENT DATE C1 MUST BE USED FOR MEDICARE CLAIMS. Y F8 Y MEDICARE ICN Y Y Y Y Y C1 Y Y ORIGINAL REFERENCE NUMBER BEGIN WITH 1 AND INCREMENT BY 1. SERVICE LINE REVENUE CODE HC HCPCS/CPT HCPCS/CPT PROCEDURE CODE. IF MEDICARE IS PRIMARY AND A MEDICARE PAYMENT IS ENTERED ON THE CLAIM AND MEDICARE DID NOT PROCESS THE CLAIM WITH A PROCEDURE CODE, THE HCPCS/CPT CODE DOES NOT HAVE TO BE SENT. 47 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG DTP NAME ID SV202 -3 SV202 -4 SV202 -5 SV202 -6 SV203 ELEMENT NAME PROCEDURE MODIFIER REQ C1 PROCEDURE MODIFIER C1 MODIFIER 2 PROCEDURE MODIFIER C1 MODIFIER 3 PROCEDURE MODIFIER C1 MODIFIER 4 MONETARY AMOUNT Y LINE ITEM CHARGE AMOUNT. PER APPENDIX A IN THE IMPLEMENTATION GUIDE, DECIMAL DATA ELEMENTS IN DATA ELEMENT 782 WILL BE LIMITED TO A MAXIMUM LENGTH OF 10 CHARACTERS INCLUDING REPORTED OR IMPLIED PLACES FOR CENTS. SV204 UNIT OR BASIS OF MEASUREMENT CODE Y SV205 SV207 QUANTITY MONETARY AMOUNT Y C1 SERVICE DATE DTP01 DTP02 DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER Y C1 Y Y VALUE DA DAYS UN UNITS SERVICE UNIT COUNT LINE ITEM DENIED CHARGE OR NONCOVERED CHARGE AMOUNT Correction of REQ based on review of X12 implementation guide. SERVICE DATE EXPRESSED IN FORMAT CCYYMMDD RANGE OF DATES EXPRESSED IN FORMAT CCYYMMDD-CCYYMMDD SERVICE DATE THIS SEGMENT IS USED FOR INPATIENT & OUTPATIENT CLAIMS. ALLOWED AMOUNT 472 D8 RD8 REF DTP03 DATE TIME PERIOD Y C2 REF01 REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFIER Y REPRICED LINE ITEM REFERENCE NUMBER REF02 REF ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER Minnesota Department of Human Services Y C2 DESCRIPTION MODIFIER 1 9B ALLOWED AMOUNT IS THE PROVIDER CONTRACTED RATE PRIOR TO ANY EXCLUSIONS OR ADD-ONS. SEE APPENDIX – P. 77 THIS SEGMENT IS USED FOR OUTPATIENT CLAIMS ONLY. 48 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG NAME ID REF01 REF02 NTE THIRD PARTY ORGANIZATION NOTES LIN THIRD PARTY NOTES Y Y C2 ITEM IDENTIFICATION C2 LIN03 PRODUCT/SERVICE ID QUALIFIER PRODUCT/SERVICE ID CTP03 UNIT PRICE Y Y CTP04 NATIONAL DRUG UNIT COUNT Y CTP05 COMPOSITE UNIT OF MEASURE UNIT OR BASIS OF MEASUREMENT CODE Y DRUG QUANTITY CTP05 -1 Minnesota Department of Human Services VALUE 9D Y DRUG IDENTIFICATION LIN02 CTP REQ Y C2 NTE01 NTE02 2410 ELEMENT NAME REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFIER Y TPO SINGLE DATE N4 Y Y DESCRIPTION PAID AMOUNT PAID AMOUNT IS THE AMOUNT PAID TO THE PROVIDER EXCLUDING THIRD PARTY LIABILITY, PROVIDER WITHHOLDS, INCENTIVES, AND MEMBER COST SHARING. SEE APPENDIX – P. 77 THIS SEGMENT IS USED FOR THE PHYSICIAN ADMINISTERED DRUG CLAIMS. MCO PAID DATE DATE OF THE PAYMENT TO THE PROVIDER FOR PHYSICIAN ADMINISTERED DRUGS. PAID DATE MUST BE SENT AS ‘PAID DATE=20120101’. USED WHEN PROC CODE MATCHES ONE ON LIST: HCPCS CODES REQUIRING NDC NATIONAL DRUG CODE (NDC) NDC FOR PHYSICIAN ADMINISTERED DRUGS. DRUG UNIT PRICE NOT USED PER X12 IG DRUG QUANTITY FOR PHYSICIAN ADMINISTERED DRUGS. F2 INTERNATIONAL UNIT GR GRAM ME MILLIGRAM ML MILLILITER UN UNIT 49 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP 2430 SEG NAME LINE ADJUDICATION INFORMATION SVD LINE ADJUDICATION INFORMATION ID VALUE DESCRIPTION THIS LOOP IS REQUIRED ONLY WHEN THERE ARE PHYSICIAN ADMINISTERED DRUGS AND THIRD PARTY LIABILITY ON THE CLAIM. IT IS REQUIRED SO THAT LINE LEVEL TPL CAN BE SUBMITTED FOR THE DRUGS. MCO ADJUDICATION INFORMATION AS A PAYER IS SUBMITTED HERE AND TPL ADJUDICATION INFORMATION, INCLUDING PHYSICIAN ADMINISTERED DRUGS. UP TO 15 OF THIS LOOP CAN BE SENT, SEND ONE PER L2330B/NM1*PR SEGMENT. OTHER PAYER PRIMARY IDENTIFIER DHS UMPI NUMBER ASSIGNED TO THE MANAGED CARE ORGANIZATION DOLLAR AMOUNT OF ALL TPL AND/OR MEDICARE PAYMENT INFORMATION. SVD01 IDENTIFICATION CODE Y SVD02 MONETARY AMOUNT Y SVD03 COMPOSITE MEDICAL PROCEDURE IDENTIFIER PRODUCT/SERVICE ID QUALIFIER PRODUCT SERVICE ID Y Y PROCEDURE CODE PROCEDURE MODIFIER C1 MODIFIER 1 PROCEDURE MODIFIER C1 MODIFIER 2 PROCEDURE MODIFIER C1 MODIFIER 3 PROCEDURE MODIFIER C1 MODIFIER 4 PRODUCT SERVICE ID QUANTITY Y Y C1 Y SERVICE LINE REVENUE CODE PAID SERVICE UNIT COUNT LINE ADJUSTMENT CAS01 Minnesota Department of Human Services REQ C1 C2 C2 SVD03 -1 SVD03 -2 SVD03 -3 SVD03 -4 SVD03 -5 SVD03 -6 SVD04 SVD05 CAS ELEMENT NAME CLAIM ADJUSTMENT GROUP CODE Y HC HCPCS/CPT CODE CO CONTRACTUAL OBLIGATIONS CR OA CORRECTIONS AND REVERSALS OTHER ADJUSTMENTS 50 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG NAME ID ELEMENT NAME REQ Y Y C1 C1 ADJUSMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE C1 C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE C1 C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE C1 C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE C1 C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE CAS18 CAS19 CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY DESCRIPTION PAYOR INITIATED REDUCTIONS PATIENT RESPONSIBILITY ADJUSTMENT REASON CODE C1 C1 Y C2 DTP01 DATE/TIME QUALIFIER Y 573 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY Correction of segment title and REQ value based on review of X12 implementation guide. DATE CLAIM PAID DTP02 Y D8 DTP03 DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD DATE EXPRESSED IN FORMAT CCYYMMDD ADJUDICATION OR PAYMENT DATE AMT01 AMT02 AMOUNT QUALIFIER CODE MONETARY AMOUNT EAF AMOUNT OWED REMAINING PATIENT LIABILITY CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 DTP AMT TRL SE DATE OR TIME OR PERIOD LINE CHECK OR REMITTANCE DATE REMAINING PATIENT LIABILITY TRAILER TRANSACTION SET TRAILER Minnesota Department of Human Services Y C1 Y Y VALUE PI PR Y 51 DHS Encounter Data 837I HIPAA Implementation Guide Data LOOP SEG NAME ID SE01 SE02 ELEMENT NAME NUMBER OF INCLUDED SEGMENTS TRANSACTION SET CONTROL NUMBER REQ Y VALUE Y DESCRIPTION TOTAL SEGMENTS IN TRANSACTION SET. MUST MATCH ST02. ENVELOPE INFORMATION INTERCHANGE CONTROL HEADER REFERENCE DESCRIPTION ELEMENT DESCRIPTION 837I VALUES ISA01 DO NOT SEND SEGMENT DELIMITERS THAT ARE MORE THAN ONE BYTE. SEE APPENDIX A.1.2.4 THROUGH A.1.2.7 IN THE 837 IMPLEMENTATION GUIDE FOR LISTS OF CHARACTERS THAT ARE ALLOWED. IF YOU SEND CHARACTERS THAT ARE NOT WITHIN THE SETS SHOWN IN THE GUIDE, YOUR FILE WILL NOT BE PROCESSED. QUALIFIER VALUES ARE CASE SENSITIVE. IF LOWER CASE VALUES ARE SENT, YOUR FILE WILL NOT BE PROCESSED. PLEASE SEND ONE INTERCHANGE PER FILE UNTIL FURTHER NOTICE. IF YOU SEND MORE THAN ONE INTERCHANGE, THE ADDITIONAL INTERCHANGES MAY NOT BE PROCESSED. AUTHORIZATION INFORMATION QUALIFIER 00-NO AUTHORIZATION INFORMATION PRESENT. ISA02 ISA03 ISA04 AUTHORIZATION INFORMATION SECURITY INFORMATION QUALIFIER SECURITY INFORMATION 10 SPACES 00-NO SECURITY INFORMATION PRESENT 10 SPACES ISA05 ISA06 INTERCHANGE ID QUALIFIER INTERCHANGE SENDER ID ISA07 INTERCHANGE ID QUALIFIER ZZ-MUTUALLY DEFINED THIS NUMBER MUST BE THE ONE USED TO REGISTER IN THE MN-ITS SYSTEM AND MUST CORRESPOND TO THE MN-ITS MAILBOX NUMBER. THIS MUST CHANGE TO THE 10-DIGIT NATIONAL PROVIDER IDENTIFIER (NPI) OR UNIVERSAL MINNESOTA PROVIDER IDENTIFIER (UMPI) FOLLOWED BY 5 TRAILING SPACES. 30-U.S. FEDERAL TAX IDENTIFICATION NUMBER ISA08 INTERCHANGE RECEIVER ID ISA09 INTERCHANGE DATE 41-1674742-MN DEPT OF HUMAN SERVICES FEIN FOLLOWED BY 5 TRAILING SPACES. THIS NUMBER MUST CONTAIN A HYPHEN. CURRENT DATE FORMATTED AS 6-DIGITS (YYMMDD) ISA10 ISA11 INTERCHANGE TIME REPETITION SEPARATOR CURRENT TIME FORMATTED AS 4-DIGITS(HHMM) PLEASE SEND DHS “[“ ISA12 INTERCHANGE CONTROL VERSION NUMBER INTERCHANGE CONTROL NUMBER 00501-DRAFT STANDARDS FOR TRIAL USE APPROVED ASC X-12 REVIEW BOARD ISA13 Minnesota Department of Human Services BEGIN WITH "1" 9-DIGIT ZERO FILLED LEFT TO RIGHT. ALL ZEROS IS NOT AN ALLOWED 52 VALUE. ISA14 ISA15 ACKNOWLEDGMENT REQUESTED USAGE INDICATOR PROVIDER OPTION 0-NO OR 1-YES. SEND P-PRODUCTION DATE FOR PRODUCTION FILES AND T-TEST DATA FOR TEST FILES. ISA16 COMPONENT ELEMENT SEPARATOR PROVIDER OPTION/SUB-ELEMENT DELIMITER. Minnesota Department of Human Services 53 INTERCHANGE CONTROL TRAILER REFERENCE DESCRIPTION ELEMENT DESCRIPTION 837I VALUES IEA01 NUMBER OF INCLUDED FUNCTIONAL PROVIDER TRANSLATOR COUNTS NUMBER OF FUNCTIONAL GROUPS WITHIN THE GROUPS INTERCHANGE. IEA02 INTERCHANGE CONTROL NUMBER SAME AS ISA13 FUNCTIONAL GROUP HEADER REFERENCE ELEMENT DESCRIPTION DESCRIPTION GS01 FUNCTIONAL IDENTIFIER CODE GS02 APPLICATION SENDER’S CODE 837I VALUES HC-HEALTH CARE CLAIMS (837) THIS MUST CHANGE TO 10-DIGIT NATIONAL PROVIDER IDENTIFIOER OR UNIVERSAL MINNESOTA PROVIDER IDENTIFIER (UMPI). MUST MATCH THE NUMBER IN ISA06 WITHOUT THE TRAILING SPACES. 41-1674742-MN DEPT OF HUMAN SERVICES FEIN. THIS NUMBER MUST CONTAIN A HYPHEN. GS03 APPLICATION RECEIVER’S CODE GS04 FUNCTIONAL GROUP CREATION DATE CURRENT DATE FORMATTED AS 8-DIGITS (CCYYMMDD). GS05 CREATION TIME CURRENT TIME FORMATTED AS 4-DIGITS (HHMM). GS06 GROUP CONTROL NUMBER UNIQUE 1-DIGIT TO 9-DIGIT NUMBER. PREFERABLY START AT 1 AND INCREMENT BY 1 FOR EACH SUCCESSIVE FUNCTIONAL GROUP FROM SENDER TO RECEIVER, AND NOT RESET TO STARTING VALUE OF 1 WITHIN EACH INTERCHANGE OR EACH DAY. GS07 RESPONSIBLE AGENCY CODE X-ACCREDITED STANDARDS COMMITTEE X-12 GS08 VERSION/RELEASE/INDUSTRY IDENTIFIER CODE 005010X223A2-DRAFT STANDARDS APPROVED BY ASC X12 BOARD. FUNCTIONAL GROUP TRAILER REFERENCE ELEMENT DESCRIPTION DESCRIPTION GE01 NUMBER OF TRANSACTION SETS INCLUDED GE02 GROUP CONTROL NUMBER Minnesota Department of Human Services 837I VALUES 1 - 6 DIGITS. PROVIDER TRANSLATOR COUNTS NUMBER OF TRANSACTION SETS WITHIN THE FUNCTIONAL GROUP. MUST MATCH GS06 NUMBER. 54 4 DENTAL 837D HIPAA Implementation Guide Data LOOP HDR SEG ST NAME ID HEADER TRANSACTION SET HEADER ST01 ST02 ST03 BHT ELEMENT NAME TRANSACTION SET IDENTIFIER CODE TRANSACTION SET CONTROL NUMBER IMPLEMENTATION CONVENTION REFERENCE BEGIN OF HIERARCHICAL TRANSACTION DHS Information REQ VALUE DESCRIPTION Y Y 837 HEALTH CARE CLAIM Y Y MCO SYSTEM GENERATED NUMBER 005010X22 4A2 SAME AS GS08 INFORMATION SOURCE, SUBSCRIBER, DEPENDENT ORIGINAL Y BHT01 BHT02 HIERARCHICAL STRUCTURE CODE TRANSACTION SET PURPOSE CODE Y 0019 Y 00 REFERENCE IDENTIFICATION DATE TIME TRANSACTION TYPE CODE Y REISSUE SUBMISSION NUMBER- MCO ASSIGNED Y Y Y TRANSACTION SET CREATION DATE TRANSACTION SET CREATION TIME REPORTING 18 BHT03 BHT04 BHT05 BHT06 1000A SUBMITTER NAME NM1 Y SUBMITTER NAME NM101 NM102 NM103 NM104 NM105 NM108 NM109 Minnesota Department of Human Services RP ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME NAME FIRST NAME MIDDLE IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE Y Y Y Y N N Y Y THIS LOOP IS USED FOR INFORMATION REGARDING THE MCO RESPONSIBLE FOR THE ENCOUNTER. 41 SUBMITTER 2 NON-PERSON ENTITY MCO NAME (OR CONTRACTOR) 46 NOT REQUIRED NOT REQUIRED TRADING PARTNER ID DHS CONTRACT ID/UMPI NUMBER OF THE MCO 55 837D HIPAA Implementation Guide Data LOOP SEG PER NAME SUBMITTER EDI CONTACT INFORMATION ID PER01 PER02 PER03 PER04 1000B NM1 NM108 NM109 HL03 HL04 Y IC INFORMATION CONTACT C1 Y TE MCO SUBMITTER CONTACT TELEPHONE COMMUNICATION NUMBER Y BILLING PROVIDER NAME BILLING PROVIDER NAME Minnesota Department of Human Services MCO CONTACT PHONE NUMBER ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE HIERARCHICAL ID NUMBER HIERARCHICAL LEVEL CODE HIERARCHICAL CHILD CODE Y 40 RECEIVER Y Y 2 NON-PERSON ENTITY MN DEPT OF HUMAN SERVICES Y 46 TRADING PARTNER ID Y Y 411674742 RECEIVER ID Y Y 1 THEN INCREMENT BY 1 Y 20 INFORMATION SOURCE Y 1 ADDITIONAL SUBORDINATE HL DATA SEGMENT IN THIS HIERARCHICAL STRUCTURE BI PXC BILLING HEALTH CARE PROVIDER TAXONOMY CODE C1 PRV03 NM1 CONTACT FUNCTION CODE NAME COMMUNICATION NUMBER QUALIFIER BILLING PROVIDER SPECIALTY INFORMATION PRV01 PRV02 2010AA DESCRIPTION BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL HIERARCHICAL LEVEL HL01 PRV VALUE Y NM102 NM103 HL REQ Y RECEIVER NAME RECEIVER NAME NM101 2000A DHS Information ELEMENT NAME PROVIDER CODE REFERENCE IDENTIFICATION QUALIFER REFERENCE IDENTIFICATION Y Y Y PROVIDER TAXONOMY CODE Y Y 56 837D HIPAA Implementation Guide Data LOOP SEG NAME ELEMENT NAME ENTITY IDENTIFIER CODE REQ Y VALUE 85 NM102 ENTITY TYPE QUALIFIER Y 1 2 NM103 NAME LAST OR ORGANIZATION NAME Y NM104 C1 NM109 BILLING PROVIDER FIRST NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE N301 ADDRESS INFORMATION N302 ADDRESS INFORMATION C1 Y N401 CITY NAME Y N402 STATE OR PROVINCE CODE POSTAL CODE C1 NM108 N3 N4 BILLING PROVIDER ADDRESS BILLING PROVIDERCITY/STATE/ZIP N403 REF BILLING PROVIDER TAX IDENTIFICATION REF02 HL REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION SUBSCRIBER HIERARCHICAL LEVEL HIERARCHICAL LEVEL XX C1 Y Y NPI PROVIDER NPI DEFAULT TO ANY TEXT NOT USED BUT REQUIRED BY STANDARD BILLING PROVIDER ADDRESS LINE BILLING PROVIDER ADDRESS LINE “ANY TEXT” BILLING PROVIDER CITY NAME MN BILLING PROVIDER STATE OR PROVINCE CODE ANY ZIP CODE BILLING PROVIDER POSTAL ZONE OR ZIP CODE C1 Y Y EI EMPLOYER’S IDENTIFICATION NUMBER BILLING PROVIDER TAX IDENTIFICATION NUMBER Y HL01 Minnesota Department of Human Services C1 DESCRIPTION BILLING PROVIDER Correction of QUALIFIER DESCRIPTION based on review of X12 implementation guide. PAY TO PROVIDER PERSON NON-PERSON ENTITY DEFAULT TO ANY TEXT-NOT USED BUT REQUIRED BY STANDARD BILLING PROVIDER LAST OR ORGANIZATIONAL NAME BILLING PROVIDER FIRST NAME Y REF01 2000B DHS Information ID NM101 HIERARCHICAL ID NUMBER Y Y START WITH 2 AND INCREMENT BY 1. 57 837D HIPAA Implementation Guide Data LOOP SEG NAME ELEMENT NAME HIERARCHICAL PARENT ID REQ Y VALUE HL03 HIERARCHICAL LEVEL CODE HIERARCHICAL CHILD CODE Y 22 Y 0 NO ADDITIONAL HL SEGMENT IN THIS HIERARCHICAL STRUCTURE Y Y U UNKNOWN Y 18 SELF Y MC MEDICAID Y IL INSURED OR SUBSCRIBER Y Y 1 PERSON MEMBER LAST NAME HL04 SBR SUBSCRIBER INFORMATION SBR01 SBR02 SBR09 2010BA NM1 NM104 NM105 NM108 NM109 ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME NAME FIRST NAME MIDDLE IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE SUBSCRIBER ADDRESS Y C1 Y Y C2 N301 ADDRESS INFORMATION SUBSCRIBER CITY, STATE, ZIP Minnesota Department of Human Services DESCRIPTION 1 FOR FIRST ITERATION. CHANGES TO PROVIDER HL01 VALUE WHEN PROVIDER NUMBER CHANGES IN A TRANSACTION SET. INFORMATION SOURCE Y NM102 NM103 N4 PAYER RESPONSIBILITY SEQUENCE NUMBER CODE INDIVIDUAL RELATIONSHIP CODE CLAIM FILING INDICATOR CODE SUBSCRIBER NAME SUBSCRIBER NAME NM101 N3 DHS Information ID HL02 Y C2 N401 CITY NAME Y N402 STATE OR PROVINCE CODE Y MI MEMBER FIRST NAME MEMBER MIDDLE INITIAL, IF KNOWN MEMBER ID NUMBER DHS ASSIGNED EIGHT DIGIT MEMBER ID SINCE THE PATIENT IS ALWAYS THE SUBSCRIBER UNDER MHCP, THIS SEGMENT IS REQUIRED. DEFAULT TO ANY TEXT – NOT USED BUT REQUIRED BY STANDARD SINCE THE PATIENT IS ALWAYS THE SUBSCRIBER UNDER MHCP, THIS SEGMENT IS REQUIRED. DEFAULT TO ANY TEXT – NOT USED BUT REQUIRED BY STANDARD DEFAULT TO ANY TEXT – NOT USED BUT REQUIRED BY STANDARD 58 837D HIPAA Implementation Guide Data LOOP SEG NAME DMG SUBSCRIBER DEMOGRAPHICS ID N403 ELEMENT NAME POSTAL CODE DMG01 DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD GENDER CODE DMG02 DMG03 REF SUBSCRIBER SECONDARY IDENTIFICATION REF02 REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION PAYER NAME NM101 NM102 NM103 NM108 NM109 REF REF02 CLM ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE BILLING PROVIDER SECONDARY IDENTIFICATION REF01 2300 REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION CLAIM INFORMATION CLAIM INFORMATION CLM01 Minnesota Department of Human Services Y Y VALUE DESCRIPTION DEFAULT TO “00000”. D8 DATE EXPRESSED IN CCYYMMDD F M U SUBSCRIBER BIRTH DATE FEMALE MALE UNKNOWN Y4 AGENCY CLAIM NUMBER Y REF01 2010BB DHS Information REQ Y Y Y CLAIM SUBMITTER’S IDENTIFIER Y Y Y Y MCO’S OWN MEMBER ID PR PAYER Y Y 2 NON-PERSON ENTITY MN DEPT OF HUMAN SERVICES Y PI PAYER ID Y C1 411674742 DHS PAYER ID Y G2 Y (REPLACES 2010AA PAY TO PROVIDER UMPI) PROVIDER COMMERCIAL NUMBER UMPI OF BILLING PAY TO PROVIDER Y Y Y MCO’S OWN CLAIM NUMBER (ICN) 59 837D HIPAA Implementation Guide Data LOOP SEG NAME ELEMENT NAME MONETARY AMOUNT REQ Y CLM05 HEALTH CARE SERVICE LOCATION INFORMATION FACILITY CODE VALUE FACILITY CODE QUALIFIER Y Y Y B CLAIM FREQUENCY TYPE CODE (CLAIM SUBMISSION REASON CODE) Y 1 PLACE OF SERVICE CODE PLACE OF SERVICE CODES FOR PROFESSIONAL OR DENTAL SERVICES. ORIGINAL 7 8 Y REPLACEMENT VOID YES (DEFAULT) N NO PROVIDER ASSIGNMENT CODE Y Y Y A C P Y Y ASSIGNED NOT ASSIGNED PATIENT REFUSES TO ASSIGN BENEFITS YES (DEFAULT) Y N W Y NO NO APPLICABLE YES (DEFAULT) CLM05-1 CLM05-2 CLM05-3 CLM06 YES/NO CONDITION RESPONSE CODE (PROVIDER SIGNATURE ON FILE CODE) Y CLM07 PROVIDER ACCEPT ASSIGNMENT CODE Y CLM08 CLM09 Minnesota Department of Human Services DHS Information ID CLM02 YES/NO CONDITION RESPONSE CODE (ASSIGNMENT OF BENEFITS CODE) RELEASE OF INFORMATION CODE (RELEASE OF INFORMATION CODE) VALUE DESCRIPTION BILLED AMOUNT. PER APPENDIX A IN THE IMPLEMENTATION GUIDE, DECIMAL DATA ELEMENTS IN DATA ELEMENT 782 WILL BE LIMITED TO A MAXIMUM LENGTH OF 10 CHARACTERS INCLUDING REPORTED OR IMPLIED PLACES FOR CENTS. 60 837D HIPAA Implementation Guide Data LOOP SEG NAME ID CLM11 CLM11-1 TO CLM11-3 DTP DTP03 DTP DTP03 DTP03 REF C1 DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD DATE- SERVICE DTP01 DTP02 AMT RELATED CAUSES INFORMATION RELATED CAUSES CODE DATE- APPLIANCE PLACEMENT DTP01 DTP02 DTP REQ DATE-ACCIDENT DTP01 DTP02 DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD PATIENT AMOUNT PAID PAYER CLAIM CONTROL NUMBER (ICN/DCN) Minnesota Department of Human Services DHS Information ELEMENT NAME VALUE I DESCRIPTION INFORMED CONSENT AA AUTO ACCIDENT EM OA EMPLOYMENT OTHER ACCIDENT C1 C1 C1 439 D8 C1 C1 Y Y ACCIDENT DATE EXPRESSED IN FORMAT CCYYMMDD ACCIDENT DATE 452 D8 Y C1 Y Y APPLIANCE PLACEMENT DATE EXPRESSED IN FORMAT CCYYMMDD APPLIANCE PLACEMENT DATE 472 D8 SERVICE DATE(S) DATE EXPRESSED IN FORMAT CCYYMMDD DATES OF SERVICE ALL TPL AND/OR MEDICARE PAYMENT INFORMATION IS SENT IN THIS SEGMENT WHETHER THE PAYMENT IS FROM THE PATIENT OR THE PROVIDER. PATIENT AMOUNT PAID. ENTER IF APPLICABLE C1 Y C1 AMT01 AMOUNT QUALIFIER CODE Y AMT02 MONETARY AMOUNT Y F5 ENTER TOTAL TPL AND/OR MEDICARE PAYMENT, IF APPLICABLE. PER APPENDIX A IN THE IMPLEMENTATION GUIDE, DECIMAL DATA ELEMENTS IN DATA ELEMENT 782 WILL BE LIMITED TO A MAXIMUM LENGTH OF 10 CHARACTERS INCLUDING REPORTED OR IMPLIED PLACES FOR CENTS. C1 61 837D HIPAA Implementation Guide Data LOOP SEG NAME ID REF01 REF02 HI HEALTH CARE INFORMATION CODES HI01-1 HEALTH CARE CODE INFORMATION CODE LIST QUALIFIER CODE DESCRIPTION PAYER CLAIM CONTROL NUMBER MCO’S ORIGINAL CLAIM (ICN) NUMBER. USED WHEN CLM05-3 IS 7REPLACEMENT OR 8-VOID. THIS IS FOR REPLACEMENT CLAIM OR VOID CLAIM USAGE ONLY. Y Y INDUSTRY CODE HEALTH CARE CODE INFORMATION Y C1 CODE LIST QUALIFIER CODE(S) Y HI02-2 THRU HI04-2 INDUSTRY CODE Y BK DO NOT SEND DECIMAL POINTS IN THE DIAGNOSIS CODE. ICD-9-CM PRINCIPAL DIAGNOSIS ABK ICD-10-CM PRINCIPAL DIAGNOSIS PRINCIPAL DIAGNOSIS CODE BF ICD-9-CM DIAGNOSIS CODE ABF ICD-10-CM DIAGNOSIS CODE DIAGNOSIS CODE 82 RENDERING PROVIDER 1 2 PERSON NON-PERSON C1 RENDERING PROVIDER NAME NM101 NM102 NM103 NM104 Minnesota Department of Human Services VALUE F8 Y HI01-2 HI02 THRU HI04 HI02-1 THRU HI04-1 RENDERING PROVIDER NAME NM1 DHS Information REQ Y C1 HI01 2310B ELEMENT NAME REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER Y Y Y NAME LAST OR ORGANIZATION NAME Y NAME FIRST C1 DEFAULT TO ANY TEXT- NOT USED BUT REQUIRED BY STANDARD. DEFAULT TO ANY TEXT- REQUIRED IF “1” IS SENT IN NM102. 62 837D HIPAA Implementation Guide Data LOOP SEG PRV NAME ID NM108 REQ Y NM109 PRV01 PROVIDER CODE Y PE PERFORMING PRV02 REFERENCE IDENTIFICATION QUALIFIER PROVIDER TAXONOMY CODE Y PXC HEALTH CARE PROVIDER TAXONOMY CODE RENDERING PROVIDER SPECIALITY INFORMATION PRV03 REF REFERENCE IDENTIFICATION REF01 REF02 2310C NM1 Y Y RENDERING PROVIDER NPI NUMBER RENDERING PROVIDER TAXONOMY CODE INFORMATION Y C2 Y DESCRIPTION NPI TAXONOMY CODE. DEFAULT TAXONOMY CODE = “777A00000Z” G2 PROVIDER COMMERCIAL NUMBER (FOR UMPI NUMBERS) DHS UMPI NUMBER SERVICE FACILITY LOCATION NAME C1 REQUIRED WHEN THE LOCATION OF HEALTH CARE SERVICE IS DIFFERENT THAN THAT CARRIED IN LOOP 2010AA. SERVICE FACILITY LOCATION NAME C1 NM102 NM103 NM108 NM109 N4 REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION VALUE XX Y NM101 N3 DHS Information ELEMENT NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER NAME LAST OR ORGANIZATION NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE SERVICE FACILITY LOCATION ADDRESS SERVICE FACILITY LOCATION CITY, STATE, ZIP CODE Minnesota Department of Human Services Y 77 SERVICE LOCATION Y Y 2 NON-PERSON ENTITY LABORATORY OR FACILITY NAME C1 XX NPI C1 LABORATORY OR FACILITY PRIMARY IDENTIFIER Y N301 ADDRESS INFORMATION Y N302 ADDRESS INFORMATION C1 LABORATORY OR FACILITY ADDRESS LINE LABORATORY OR FACILITY ADDRESS LINE Y 63 837D HIPAA Implementation Guide Data LOOP SEG NAME ELEMENT NAME CITY NAME REQ Y N402 STATE OR PROVINCE CODE POSTAL CODE C1 N403 REF SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION REF02 NM1 REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION SUPERVISING PROVIDER NAME SUPERVISING PROVIDER NAME DESCRIPTION LABORATORY OR FACILITY CITY NAME LABORATORY OR FACILITY STATE OR PROVINCE CODE LABORATORY OR FACILITY POSTAL ZONE OR ZIP CODE G2 PROVIDER COMMERCIAL NUMBER (FOR UMPI NUMBERS) C1 Y Y LABORATORY OR FACILITY SECONDARY IDENTIFIER (DHS UMPI NUMBER) C1 Y NM101 NM102 NM103 NM108 NM109 REF VALUE C1 REF01 2310E DHS Information ID N401 ENTITY ID CODE ENTITY TYPE QUALIFIER NAME LAST/ORG NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE REFERENCE IDENTIFICATION Y Y Y Y DQ 1 XX Y SUPERVISING PROVIDER PERSON SUPERVISING PROVIDER LAST NAME CMS NATIONAL PROVIDER IDENTIFIER SUPERVISING PROVIDER IDENTIFIER (NPI) C1 SUPERVISION PROVIDER SECONDARY IDENTIFIER REF01 REF02 Minnesota Department of Human Services REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION Y Y G2 PROVIDER COMMERCIAL NUMBER (FOR UMPI NUMBERS) DHS UMPI NUMBER 64 837D HIPAA Implementation Guide Data LOOP 2320 SEG NAME OTHER SUBSCRIBER INFORMATION SBR OTHER SUBSCRIBER INFORMATION ID ELEMENT NAME DHS Information REQ C2 VALUE DESCRIPTION THIS LOOP IS REQUIRED - THE FIRST OCCURRENCE MUST CONTAIN INFORMATION FOR THE MCO AS THE PRIMARY/SECONDARY PAYER. IF THE PRIMARY PAYER IS A THIRD PARTY, THE SECOND OCCURRENCE OF THIS SEGMENT SHOULD CONTAIN A “P” AND INFORMATION RELATED TO THE RELEVANT THIRD PARTY PAYER. UP TO 10 SBR LOOPS CAN BE SENT. Y P PRIMARY SECONDARY TERTIARY REFER TO THE IMPLEMENTATION GUIDE FOR THE OTHER CODES/VALUES Y S T SEE X12 IG FOR ADDT’L CODES/ VALUES 18 Y SBR01 SBR02 PAYER RESPONSIBILITY SEQUENCE NUMBER CODE INDIVIDUAL RELATIONSHIP CODE SEE X12 IG FOR ADDT’L CODES/ VALUES SBR03 SBR05 SBR09 REFERENCE IDENTIFICATION INSURANCE TYPE CODE C1 CLAIM FILING INDICATOR CODE Y C1 SEE X12 IG FOR ADDT’L CODES/ VALUES HM 11 Minnesota Department of Human Services SELF– this is the only option for the first occurrence. Subsequent occurrences should be billed as appropriate. REFER TO THE IMPLEMENTATION GUIDE FOR THE OTHER CODES/VALUES INSURANCE GROUP OR POLICY NUMBER REQUIRED WHEN MEDICARE PRESENT AND MEDICARE IS NOT PRIMARY PAYER. HEALTH MAINTENANCE ORGANIZATION (HM) – This is only for the first occurrence. On subsequent occurrences, fill out as appropriate. OTHER NON-FEDERAL PROGRAMS 65 837D HIPAA Implementation Guide Data LOOP SEG CAS NAME ID ELEMENT NAME CLAIM LEVEL ADJUSTMENTS DHS Information REQ VALUE SEE X12 IG FOR ADDT’L CODES/ VALUES C1 CAS01 CLAIM ADJUSTMENT GROUP CODE Y CO CR OA PI PR CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19 AMT CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY COB PAYER PAID AMOUNT AMT01 Minnesota Department of Human Services AMOUNT QUALIFIER CODE DESCRIPTION REFER TO THE IMPLEMENTATION GUIDE FOR THE OTHER CODES/VALUES COMPLETE IF YOU HAVE CLAIM LEVEL ADJUSTMENTS CONTRACTUAL OBLIGATIONS Y CORRECTIONS AND REVERSALS OTHER ADJUSTMENTS PAYOR INITIATED REDUCTIONS PATIENT RESPONSIBILITY ADJUSTMENT REASON Y C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON C1 C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON C1 C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON C1 C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON C1 C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON C1 C1 C2 Y ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY D PAYOR PAID AMOUNT 66 837D HIPAA Implementation Guide Data LOOP SEG NAME AMT REMAINING PATIENT LIABILITY ID AMT02 ELEMENT NAME MONETARY AMOUNT AMT01 AMOUNT QUALIFIER CODE MONETARY AMOUNT AMT02 AMT COB TOTAL NON-COVERED AMOUNT AMT01 AMT02 OI OI06 2330A Y C1 REMAINING PATIENT LIABILITY Y Y Y Y OTHER SUBSCRIBER NAME NM101 NM102 ENTITY ID CODE ENTITY TYPE QUALIFIER NM103 NAME LAST OR ORGANIZATION NAME NAME FIRST NAME MIDDLE NAME SUFFIX ID CODE QUALIFIER ID CODE OTHER PAYER NAME NM101 NM102 Minnesota Department of Human Services AMOUNT OWED YES/NO CONDITION OR RESPONSE RELEASE OF INFORMATION OTHER PAYER NAME NM1 EAF A8 Y Y ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER Y Y Y Y C1 C1 C1 Y Y C2 NONCOVERED CHARGES – ACTUAL NON-COVERED CHARGE AMOUNT C1 NM104 NM105 NM107 NM108 NM109 2330B DESCRIPTION PAYER PAID AMOUNT; ZERO IS ACCEPTABLE Y OTHER SUBSCRIBER NAME NM1 C1 Y VALUE AMOUNT QUALIFIER CODE MONETARY AMOUNT OTHER INSURANCE COVERAGE INFORMATION OI03 DHS Information REQ Y ONE SUBSCRIBER NAME PER SBR SEGMENT. IL 1 2 UNKNOWN INSURED OR SUBSCRIBER PERSON NON-PERSON ENTITY MI UNKNOWN MEMBER IDENTIFICATION NUMBER THIS LOOP IS REQUIRED – MCO ADJUDICATION INFORMATION AS A PAYER IS SUBMITTED HERE AND TPL ADJUDICATION INFORMATION, ONE OTHER PAYER NAME PER SBR SEGMENT. Y Y PR PAYER Y 2 NON-PERSON ENTITY 67 837D HIPAA Implementation Guide Data LOOP SEG NAME ID NM103 NM108 NM109 DTP CLAIM CHECK OR REMITTANCE DATE DTP03 REF02 LX SV3 DESCRIPTION Y PI PAYOR IDENTIFICATION Y Y Y REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION Y SERVICE LINE LINE NUMBER LX01 ASSIGNED NUMBER SV301 COMPOSITE MEDICAL PROCEDURE IDENTIFIER PRODUCT SERVICE ID QUALIFIER PRODUCT/SERVICE ID PROCEDURE MODIFIER PROCEDURE MODIFIER PROCEDURE MODIFIER PROCEDURE MODIFIER DENTAL SERVICE SV301-1 SV301-2 SV301-3 SV301-4 SV301-5 SV301-6 Minnesota Department of Human Services VALUE UNKNOWN DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD OTHER PAYER CLAIM CONTROL NUMBER REF01 2400 DHS Information REQ Y OTHER PAYER PRIMARY IDENTIFIER DHS UMPI NUMBER ASSIGNED TO THE MANAGED CARE ORGANIZATION C1 DTP01 DTP02 REF ELEMENT NAME NAME LAST OR ORGANIZATION NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE 573 D8 DATE CLAIM PAID DATE EXPRESSED IN CCYYMMDD F8 ADJUDICATION OR PAYMENT DATE MUST BE USED FOR MEDICARE CLAIMS. ORIGINAL REFERENCE NUMBER Y C1 Y OTHER PAYER’S CLAIM CONTROL NUMBER Y Y Y BEGINS WITH 1 AND INCREMENTED BY 1 Y Y Y Y C1 C1 C1 C1 AD ADA PROCEDURE ADA PROCEDURE CODE MODIFIER 1 MODIFIER 2 MODIFIER 3 MODIFIER 4 68 837D HIPAA Implementation Guide Data LOOP SEG NAME ELEMENT NAME MONETARY AMOUNT REQ Y SV303 FACILITY CODE VALUE Y SV304 ORAL CAVITY DESIGNATION ORAL CAVITY DESIGNATION CODE C1 SV304-1 SV305 SV306 SV311-1 SV311-2 THRU SV311-4 TOO PROSTHESIS, CROWN OR INLAY CODE QUANTITY DIAGNOSIS CODE POINTER DIAGNOSIS CODE POINTER TOOTH INFORMATION VALUE DESCRIPTION LINE ITEM CHARGE AMOUNT. PER APPENDIX A IN THE IMPLEMENTATION GUIDE, DECIMAL DATA ELEMENTS IN DATA ELEMENT 782 WILL BE LIMITED TO A MAXIMUM LENGTH OF 10 CHARACTERS INCLUDING REPORTED OR IMPLIED PLACES FOR CENTS. OVERRIDE CLM05-1 IN LOOP 2300 WHEN PLACE OF SERVICE IS DIFFERENT THAN THE VALUE SENT AT THE CLAIM LEVEL. Y 10 UPPER RIGHT QUADRANT C1 20 30 40 I UPPER LEFT QUADRANT LOWER LEFT QUADRANT LOWER RIGHT QUADRANT INITIAL R Y Y REPLACEMENT UNITS OF SERVICE PRIMARY DIAGNOSIS CODE POINTER C1 DIAGNOSIS CODE POINTER C1 TOO01 TOO02 TOO03 TOO03-1 Minnesota Department of Human Services DHS Information ID SV302 CODE LIST QUALIFIER CODE INDUSTRY CODE TOOTH SURFACE TOOTH SURFACE CODE Y Y C1 Y JP NATIONAL STANDARD TOOTH NUMBER TOOTH NUMBER B D F I L M O BUCCAL DISTAL FACIAL INCISAL LINGUAL MESIAL OCCLUSAL 69 837D HIPAA Implementation Guide Data LOOP SEG DTP DTP DTP REF NAME ELEMENT NAME TOOTH SURFACE CODE REQ C1 TOO03-3 TOOTH SURFACE CODE C1 TOO03-4 TOOTH SURFACE CODE C1 TOO03-5 TOOTH SURFACE CODE C1 DTP01 DTP02 DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER DATE – SERVICE DATE C1 Y Y DTP03 DATE TIME PERIOD DTP01 DTP02 DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER DTP03 DATE TIME PERIOD Y C2 DTP01 DTP02 DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER Y Y DTP03 DATE TIME PERIOD Y C1 REF01 REFERENCE IDENTIFICATION QUALIFIER DATE- PRIOR PLACEMENT DATE- REPLACEMENT LINE ITEM CONTROL NUMBER Minnesota Department of Human Services DHS Information ID TOO03-2 Y C1 Y Y VALUE REPEAT OF VALUES ABOVE REPEAT OF VALUES ABOVE REPEAT OF VALUES ABOVE REPEAT OF VALUES ABOVE DESCRIPTION REPEAT OF VALUES ABOVE 472 D8 SERVICE DATE(S) DATE EXPRESSED IN FORMAT CCYYMMDD RD8 DATE EXPRESSED IN FORMAT CCYYMMDD-CCYYMMDD SERVICE DATE 441 D8 PRIOR PLACEMENT DATE EXPRESSED IN FORMAT CCYYMMDD REPEAT OF VALUES ABOVE REPEAT OF VALUES ABOVE REPEAT OF VALUES ABOVE PRIOR PLACEMENT DATE MCO PAID DATE 446 D8 PAID DATE DATE EXPRESSED IN FORMAT CCYYMMDD DATE OF PAYMENT TO THE PROVIDER 6R LINE ITEM CONTROL NUMBER 70 837D HIPAA Implementation Guide Data LOOP SEG REF NAME ID REF02 ELEMENT NAME REFERENCE IDENTIFICATION REF01 REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION REPRICED CLAIM NUMBER REF02 REF ADJUSTED REPRICED CLAIM NUMBER REF02 REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION RENDERING PROVIDER NAME NM1 C2 Y VALUE DESCRIPTION MCO’S LINE ITEM CONTROL NUMBER 9A PAID AMOUNT Y PAID AMOUNT IS THE AMOUNT PAID TO THE PROVIDER EXCLUDING THIRD PARTY LIABILITY, PROVIDER WITHHOLDS, INCENTIVES AND MEMBER COST SHARING SEE APPENDIX – P. 77 C2 REF01 2420A DHS Information REQ C1 Y 9C Y ALLOWED AMOUNT ALLOWED AMOUNT IS DEFINED AS THE PROVIDER CONTRACTED RATE PRIOR TO ANY EXCLUSIONS OR ADD ONS. SEE APPENDIX – P. 77 OVERRIDE 2310B LOOP IF THE RENDERING PROVIDER ON A LINE ITEM IS DIFFERENT THAN THE NUMBER SUBMITTED AT THE CLAIM LEVEL. C1 RENDERING PROVIDER NAME NM101 NM102 NM103 NM104 NM108 NM109 Minnesota Department of Human Services ENTITY IDENTIFIER CODE ENTITY TYPE QUALIFIER Y 82 RENDERING PROVIDER Y 1 2 NAME LAST OR ORGANIZATION NAME NAME FIRST Y PERSON NON-PERSON RENDERING PROVIDER NAME IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE C1 Y Y XX ANY TEXT- REQUIRED IF “1” IS SENT IN NM102. NPI RENDERING PROVIDER NPI NUMBER IF XX 71 837D HIPAA Implementation Guide Data LOOP 2420A SEG NAME RENDERING PROVIDER SPECIALITY INFORMAITON ID REQ Y VALUE DESCRIPTION RENDERING PROVIDER TAXONOMY CODE INFORMATION PRV01 PROVIDER CODE Y PE PERFORMING PRV02 REFERENCE IDENTIFICATION QUALIFIER PROVIDER TAXONOMY CODE Y PXC HEALTH CARE PROVIDER TAXONOMY CODE PRV03 REF REFERENCE IDENTIFICATION REF01 REF02 2420C DHS Information ELEMENT NAME REFERENCE IDENTIFICATION QUALIFIER REFERENCE IDENTIFICATION Y C1 Y TAXONOMY CODE – DEFAULT TO 777A000002. G2 Y DHS UMPI NUMBER. C1 OVERRIDES 2310E LOOP IF THE SUPERVISING PROVIDER ON A LINE ITEM IS DIFFERENT THAN THE NUMBER SUBMITTED AT THE CLAIM LEVEL. SUPERVISING PROVIDER NAME NM1 SUPERVISING PROVIDER NAME Y NM101 ENTITY ID CODE Y DQ SUPERVISING PROVIDER NM102 ENTITY TYPE QUALIFIER Y 1 PERSON NM103 NAME LAST/ORG NAME Y NM108 IDENTIFICATION CODE QUALIFIER IDENTIFICATION CODE C1 NM109 2430 LINE ADJUDICATION INFORMATION SVD LINE ADJUDICATION INFORMATION Minnesota Department of Human Services PROVIDER COMMERCIAL NUMBER (FOR UMPI NUMBERS) C1 C1 SUPERVISING PROVIDER LAST NAME XX CMS NATIONAL PROVIDER IDENTIFIER SUPERVISING PROVIDER IDENTIFIER THIS LOOP IS REQUIRED. MCO ADJUDICATION INFORMATION AS A PAYER IS SUBMITTED HERE AND TPL ADJUDICATION INFORMATION YOU CAN SEND UP TO 15 OF THESE; SEND ONE PER L2330B/NM1*PR SEGMENT. Y SVD01 IDENTIFICATION CODE Y SVD02 MONETARY AMOUNT Y OTHER PAYER PRIMARY IDENTIFIER DHS UMPI NUMBER ASSIGNED TO THE MANAGED CARE ORGANIZATION 72 837D HIPAA Implementation Guide Data LOOP SEG NAME ID SVD03 SVD03-1 SVD03-2 SVD03-3 SVD03-4 SVD03-5 SVD03-6 SVD05 CAS ELEMENT NAME COMPOSITE MEDICAL PROCEDURE PRODUCT/SERVICE ID QUALIFIER PRODUCT SERVICE ID PROCEDURE MODIFIER PROCEDURE MODIFIER PROCEDURE MODIFIER PROCEDURE MODIFIER QUANTITY LINE ADJUSTMENT CAS01 CAS02 CAS03 CAS04 CAS05 CAS06 CAS07 CAS08 CAS09 CAS10 CAS11 CAS12 CAS13 CAS14 CAS15 CAS16 CAS17 CAS18 CAS19 Minnesota Department of Human Services CLAIM ADJUSTMENT GROUP CODE CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY CLAIM ADJUSTMENT REASON CODE MONETARY AMOUNT QUANTITY DHS Information REQ Y VALUE DESCRIPTION Y AD Y C1 C1 C1 C1 Y C1 Y AMERICAN DENTAL ASSOCIATION CODES PROCEDURE CODE MODIFIER 1 MODIFIER 2 MODIFIER 3 MODIFIER 4 PAID SERVICE UNITS COUNT CO CONTRACTUAL OBLIGATIONS CR OA PI PR Y CORRECTION AND REVERSALS OTHER ADJUSTMENTS PAYOR INITIATED REDUCTIONS PATIENT RESPONSIBILITY ADJUSTMENT REASON CODE Y C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE Y C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE Y C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE Y C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE Y C1 C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY ADJUSTMENT REASON CODE Y C1 ADJUSTMENT AMOUNT ADJUSTMENT QUANTITY 73 837D HIPAA Implementation Guide Data LOOP SEG DTP NAME DATE OR TIME OR PERIOD ID DTP01 DTP02 DTP03 AMT AMT02 SE DATE/TIME QUALIFIER DATE TIME PERIOD FORMAT QUALIFIER DATE TIME PERIOD REMAINING PATIENT LIABILITY AMT01 TRL ELEMENT NAME AMOUNT QUALIFIER CODE MONETARY AMOUNT TRAILER TRANSACTION SET TRAILER SE01 SE02 TRANSACTION SEGMENT COUNT TRANSACTION SET CONROL NUMBER DHS Information REQ Y Y Y 573 D8 Y C1 Y DESCRIPTION MEDICARE OR PAYER PAID DATE DATE CLAIM PAID DATE EXPRESSED IN FORMAT CCYYMMDD ADJUDICATION OR PAYMENT DATE EAF AMOUNT OWED Y Y Y Y VALUE REMAINING PATIENT LIABILITY TOTAL SEGMENTS IN TRANSACTION SET. MUST MATCH ST02. ENVELOPE INFORMATION INTERCHANGE CONTROL HEADER REFERENCE DESCRIPTION ISA01 ISA02 ISA03 ISA04 ISA05 ISA06 ELEMENT DESCRIPTION AUTHORIZATION INFORMATION QUALIFIER AUTHORIZATION INFORMATION SECURITY INFORMATION QUALIFIER SECURITY INFORMATION 837D VALUES DO NOT SEND SEGMENT DELIMITERS THAT ARE MORE THAN ONE BYTE. SEE APPENDIX A.1.2.4 THROUGH A.1.2.7 IN THE 837 IMPLEMENTATION GUIDE FOR LISTS OF CHARACTERS THAT ARE ALLOWED. IF YOU SEND CHARACTERS THAT ARE NOT WITHIN THE SETS SHOWN IN THE GUIDE, YOUR FILE WILL NOT BE PROCESSED. QUALIFIER VALUES ARE CASE SENSITIVE. IF LOWER CASE VALUES ARE SENT, YOUR FILE WILL NOT BE PROCESSED. PLEASE SEND ONE INTERCHANGE PER FILE UNTIL FURTHER NOTICE. IF YOU SEND MORE THAN ONE INTERCHANGE, THE ADDITIONAL INTERCHANGES MAY NOT BE PROCESSED. 00-NO AUTHORIZATION INFORMATION PRESENT. 10 SPACES 00-NO SECURITY INFORMATION PRESENT 10 SPACES INTERCHANGE ID QUALIFIER ZZ-MUTUALLY DEFINED INTERCHANGE SENDER ID THIS NUMBER MUST BE THE ONE USED TO REGISTER IN THE MN-ITS SYSTEM AND MUST CORRESPOND TO THE MN-ITS MAILBOX NUMBER. THIS MUST CHANGE TO THE 10-DIGIT NATIONAL PROVIDER IDENTIFIER (NPI) OR UNIVERSAL MINNESOTA PROVIDER IDENTIFIER (UMPI) Minnesota Department of Human Services 74 FOLLOWED BY 5 TRAILING SPACES. ISA07 ISA08 ISA09 ISA10 INTERCHANGE ID QUALIFIER 30-U.S. FEDERAL TAX IDENTIFICATION NUMBER INTERCHANGE RECEIVER ID 41-1674742-MN DEPT OF HUMAN SERVICES FEIN FOLLOWED BY 5 TRAILING SPACES. THIS NUMBER MUST CONTAIN A HYPHEN. INTERCHANGE DATE CURRENT DATE FORMATTED AS 6-DIGITS (YYMMDD) INTERCHANGE TIME CURRENT TIME FORMATTED AS 4-DIGITS(HHMM) ISA11 REPETITION SEPARATOR PLEASE SEND DHS “[“ ISA12 INTERCHANGE CONTROL VERSION NUMBER INTERCHANGE CONTROL NUMBER ACKNOWLEDGMENT REQUESTED USAGE INDICATOR COMPONENT ELEMENT SEPARATOR 00501-DRAFT STANDARDS FOR TRIAL USE APPROVED ASC X-12 REVIEW BOARD ISA13 ISA14 ISA15 ISA16 BEGIN WITH "1" 9-DIGIT ZERO FILLED LEFT TO RIGHT. ALL ZEROS IS NOT AN ALLOWED VALUE. PROVIDER OPTION 0-NO OR 1-YES. SEND P-PRODUCTION DATE FOR PRODUCTION FILES AND T-TEST DATA FOR TEST FILES. PROVIDER OPTION/SUB-ELEMENT DELIMITER. INTERCHANGE CONTROL TRAILER REFERENCE DESCRIPTION ELEMENT DESCRIPTION 837D VALUES IEA01 NUMBER OF INCLUDED FUNCTIONAL PROVIDER TRANSLATOR COUNTS NUMBER OF FUNCTIONAL GROUPS WITHIN THE GROUPS INTERCHANGE. IEA02 INTERCHANGE CONTROL NUMBER SAME AS ISA13 FUNCTIONAL GROUP HEADER REFERENCE ELEMENT DESCRIPTION DESCRIPTION GS01 FUNCTIONAL IDENTIFIER CODE GS02 APPLICATION SENDER’S CODE GS03 GS04 GS05 APPLICATION RECEIVER’S CODE FUNCTIONAL GROUP CREATION DATE CREATION TIME Minnesota Department of Human Services 837D VALUES HC-HEALTH CARE CLAIMS (837) THIS MUST CHANGE TO 10-DIGIT NATIONAL PROVIDER IDENTIFIOER OR UNIVERSAL MINNESOTA PROVIDER IDENTIFIOER (UMPI). MUST MATCH THE NUMBER IN ISA06 WITHOUT THE TRAILING SPACES. 41-1674742-MN DEPT OF HUMAN SERVICES FEIN. THIS NUMBER MUST CONTAIN A HYPHEN. CURRENT DATE FORMATTED AS 8-DIGITS (CCYYMMDD). CURRENT TIME FORMATTED AS 4-DIGITS (HHMM). 75 GS06 GROUP CONTROL NUMBER GS07 RESPONSIBLE AGENCY CODE GS08 VERSION/RELEASE/INDUSTRY IDENTIFIER CODE UNIQUE 1-DIGIT TO 9-DIGIT NUMBER. PREFERABLY START AT 1 AND INCREMENT BY 1 FOR EACH SUCCESSIVE FUNCTIONAL GROUP FROM SENDER TO RECEIVER, AND NOT RESET TO STARTING VALUE OF 1 WITHIN EACH INTERCHANGE OR EACH DAY. X-ACCREDITED STANDARDS COMMITTEE X-12 005010X224A2-DRAFT STANDARDS APPROVED BY ASC X12 BOARD. FUNCTIONAL GROUP TRAILER REFERENCE ELEMENT DESCRIPTION DESCRIPTION GE01 NUMBER OF TRANSACTION SETS INCLUDED GE02 GROUP CONTROL NUMBER Minnesota Department of Human Services 837D VALUES 1 - 6 DIGITS. PROVIDER TRANSLATOR COUNTS NUMBER OF TRANSACTION SETS WITHIN THE FUNCTIONAL GROUP. MUST MATCH GS06 NUMBER. 76 APPENDIX – PAID AMOUNT AND ALLOWED AMOUNT RULES • • • • • • • • • • • Include decimal in the value, so it represents dollars and cents: xx.xx Do not include commas 0.00 is valid, but a negative number is not Submit paid amount only on the CPT/HCPCS code line for which payment was determined or made. Submit this amount only once. All other lines within the same claim where payment is inclusive of another line should be sent with 0.00 in the paid amount Do not repeat the paid amount on every line within the claim All subsequent claims that are part of a package payment, where no additional payment is made (e.g., a global or surgical claim), submit 0.00 in the paid amount For any claim services that are payable outside of the global CPT/HCPCS code (e.g. physician-administered drugs), submit the paid amounts on the related line Capitated services should be submitted if they are calculated and go through the claim system, by line or on one line as is appropriate 837P –individual paid amounts are at line level 837I – claim total paid is on the header; individual paid amounts are at line level, according to the level at which payment was made. For example, if an inpatient claim is paid according to a DRG, the amount is at the header. If there are additional procedures which are paid on the claim, those are on lines. The total paid for the DRG and any additional payments is on the header. A different example is inpatient CD residential treatment, which is paid at the line. The total paid for the claim is put on the header. Minnesota Department of Human Services 77
© Copyright 2024