1. health and fitness

COMPANION GUIDE FOR THE HIPAA 837 PROFESSIONAL
CLAIM, VERSION 5010
COMPANION GUIDE
FOR THE
HIPAA 837 PROFESSIONAL CLAIM
VERSION 5010A1
Effective Date: January 1, 2012
Version Date: June 13, 2013
HAP Midwest Health Plan, Inc.
4700 Schaefer Road, Suite 340
Dearborn, MI 48126
Phone (888) 654-2200 Fax (313) 581-2780
hap.org./midwest
6/26/2014
1
COMPANION GUIDE FOR THE HIPAA 837 PROFESSIONAL
CLAIM, VERSION 5010
Introduction:
This document is intended as a companion to the Health Care Professional Claim, ASC
X12N 837P (005010X222) 837P Health Care Claim: Professional Technical Report 3
(TR3) dated May 2006. This document also includes updates appearing in:
 Errata 005010X222E1 • 837 Health Care Claim: Professional dated January
2009
 Errata 005010X222A1 • 837 Health Care Claim: Professional dated June 2010
This document should be used in conjunction with all HAP Midwest Health Plan Claim
submission and processing guidelines.
For more information on the TR3, please refer to the Washington Publishing Company
website at http://www.wpc-edi.com
Transaction Description:
This transaction set is used to exchange institutional health care claim information from
providers of health care services. This transaction can be submitted either directly or via
intermediary billing services and/or claims clearinghouses.
Upload/Submission Notes for ANSI ASC X12 837P Health Care Claim:
Please refer to the HAP Midwest Health Plan Electronic Submission Manual (MHPXXX)
for information regarding:





Submitter setup and trading partner B2B testing
Direct upload to HAP Midwest Health Plan using HTTPS secure file upload
Secure FTP submission
Interchange Acknowledgement (TA1) transaction
Interchange Acknowledgement (999) transaction
Naming Convention of File
Submitter id followed by 837P followed by your internal# followed by date time with .EDI
extension. Sample where Submitter id is SBM123
SBM123837PXXXX201201011157.EDI
HAP Midwest Health Plan, Inc.
4700 Schaefer Road, Suite 340
Dearborn, MI 48126
Phone (888) 654-2200 Fax (313) 581-2780
hap.org./midwest
6/26/2014
2
COMPANION GUIDE FOR THE HIPAA 837 PROFESSIONAL
CLAIM, VERSION 5010
837P – Transaction Set
Please note that Professional and Institutional claims may NOT be batched together
within the same ISA/IEA. Each must be batched within its own ISA/IEA envelope.
Loop
Segment
Data
Element
ST –
Transaction
Set Header
HAP Midwest Health Plan Rules
HAP Midwest Health Plan accepts a
maximum of 5,000 CLM segments in a
single transaction (ST-SE) as
recommended by the HIPAA-mandated
Implementation Guide.
NM108 –
Identification
Code
Qualifier
NM109 –
Billing
Provider
Identifier
N301 – Billing
Provider
Address Line
1
REF01 –
Reference
Identification
Qualifier
Use “XX” for National Provider
Identification
REF – Billing
Provider
Secondary
Identification
REF02 –
Billing
Provider
Additional
Identifier
Use Employer’s Identification Number
(EIN).
2010AB — Pay-To
Address Name
N3- Pay – To
Address –
Address
N301- Address
Information
2010BA SUBSCRIBER
NAME
NM1 Individual or
Organizational
Name
NM108 Identification
Code
Qualifier
Must match Pay to address currently on
file at MWHP can verify thru MWHP
website - Verify vendor info or under
provider quick links “Is my payment
address with you correct?”
Use “MI” - Member Identification Number
2010AA – Billing
Provider Name
NM1 – Billing
Provider Name
2010AA – Billing
Provider Name
NM1 – Billing
Provider Name
2010AA - Billing
Provider Name
N3 – Billing
Provider
Address
2010AA – Billing
Provider Name
REF – Billing
Provider
Secondary
Identification
2010AA – Billing
Provider Name
Use the National Provider Identification
(NPI) Should be Group NPI (Line 33a
HCFA)
Maximum length of 24 characters
Use “EI” Employer’s Identification
Number (EIN).
HAP Midwest Health Plan, Inc.
4700 Schaefer Road, Suite 340
Dearborn, MI 48126
Phone (888) 654-2200 Fax (313) 581-2780
hap.org./midwest
6/26/2014
3
COMPANION GUIDE FOR THE HIPAA 837 PROFESSIONAL
CLAIM, VERSION 5010
2010BA SUBSCRIBER
NAME
NM1 Individual or
Organizational
Name
NM109 Identification
Code
Use Subscriber Primary Identifier from the
Member ID CARD.
(This is a 10, 9 or 8 character field). **
2010BA SUBSCRIBER
NAME
NM1 Individual or
Organizational
Name
NM103NM104 – Last
name, First
name
Must match what MWHP has in their
database. Can verify on MWHP website
2010BA SUBSCRIBER
NAME
DMG –
Subscriber
Demographic
information
NTE Note/Special
Instruction
DMG02- Date
of Birth|
DMG03 Gender
NTE02 Description
Must match what MWHP has in their
database. Can verify on MWHP website
HI – Health
Care Diagnosis
Code
HI – Health
Care Diagnosis
Code
NM1 –
Rendering
Provider Name
HI01 –
Principal
Diagnosis
HI01 –
Additional
Diagnosis
NM108 –
Identification
Code
Qualifier
NM1 SERVICE
FACILITY
LOCATION
NAME
SV1 –
Professional
Service
NM103 Laboratory or
Facility Name
2300 – Claim
Information
2310 - Health Care
Diagnosis Code
2310 - Health Care
Diagnosis Code
2310B – Rendering
Provider Name
2310C — SERVICE
FACILITY
LOCATION NAME
2400 – Service Line
Number
SV107 –
Comp. Diag.
Cod Pointer
When used for Prenatal visits format
should be the letters OB followed by colon
by dates (mmddyy) of visits separated by
semicolons exampleOB:MMDDYY;MMDDYY ***
Cannot be an External cause of Injury
code
Cannot duplicate codes
Required by HAP Midwest Health Plan
even if same as billing. Use “XX” for
National Provider Identification (NPI)
Should be an Individual NPI (line 24J
HCFA)
As of 6/2013, required when the location
of health care service is different than
that carried in Loop ID-2010AA (Billing
Provider).
The pointer must point to a diagnosis code
and cannot skip a segment
** Member ID is 10 digits Beneficiary ID for MEDICAID and ABW members
(0012345678), 9 digits for HAP Midwest Health Plan Medicare Advantage members
(000991234), 9 digits for Wayne County Health Choice Members (120012345), and
HAP Midwest Health Plan, Inc.
4700 Schaefer Road, Suite 340
Dearborn, MI 48126
Phone (888) 654-2200 Fax (313) 581-2780
hap.org./midwest
6/26/2014
4
COMPANION GUIDE FOR THE HIPAA 837 PROFESSIONAL
CLAIM, VERSION 5010
alpha-numeric ID for Macomb Care Connect (B0502001).
PRENATAL VISITS ***
 When billing with the Antepartum Care Procedure Codes 59425 or 59426
procedure Code and Pre-Natal visits must be reported use NTE segment
in Loop 2300 the Reference code should be ADD and the description
format should be the letters OB followed by colon by pre-natal dates
(mmddyy) of visits separated by semicolons no other separators in the
date is excepted. example- OB:MMDDYY;MMDDYY;MMDDYY
This document has been prepared as a Midwest Health Plan specific companion
document to that implementation guide and to provide instructions to providers for some
of the data elements. This companion guide document supplements, but does not
contradict any requirements in the 837 Professional version 5010A1 implementation
guide or Midwest Health Plan Claim Submission Information Manual..
Please refer to Claims Submission Information Manual at hap.org/midwest
for more information.
HAP Midwest Health Plan, Inc.
4700 Schaefer Road, Suite 340
Dearborn, MI 48126
Phone (888) 654-2200 Fax (313) 581-2780
hap.org./midwest
6/26/2014
5