837 Professional Claims Standard Companion Guide for ... · pr odu ct ion). F exam l , h est file...

837 Professional Claims Standard Companion Guide

for Submitters

To be used in conjunction with the Implementation Guide and Addenda for ASC X12N 837 Version 004010X098A1

January 2008

MD On‐Line, Inc. Confidential Jan. 2008

2

January 2008

Disclosure Statement

This document is intended to be a companion guide for use in conjunction with the ASCX12N National Electronic Data Interchange Transaction Set Implementation and Addenda Guides. The information in this document is provided by MD On‐Line, Inc. for its associated Trading Partners.

This document contains clarifications as permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Standard for Electronic Transactions. This document is not intended to convey information that exceeds the requirements or usages of data expressed in the ASCX12N National Electronic Data Interchange Transaction Set Implementation and Addenda Guides defined by HIPAA.

MD On‐Line, Inc. may make improvements and/or changes to the information contained in this document without notice.

This document may not be copied and distributed without direct permission from MD On‐Line, Inc.

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Preface

This companion Guide to the ASC X12N Implementation Guides, adopted under HIPAA, clarifies and spe ifies the data content being requested when data is transmitted to MD On‐Line. Transmissions based on this companion document, used in tandem with the X12N Implementation Guides, are compliant with both X12 syntax and the Implementation Guides.

This companion guide is intended only to assist submitters with information to be supplied to MD On‐Line (MDOL) in the Professional Health Care Claim transaction (837 Professional). This guide only addresses information fields that:

� consist of information which MDOL is required to or allowed to supply to trading

partners

� are identified as mutually defined

� are defined by specific payer(s)

Submitters must use the National Electronic Data Interchange Transaction Set Implementation Guide for the Professional Health Care Claim transaction (837 Professional) for complete instructions on submitting this transaction. This companion guide does not modify any of the requirements of the Implementation Guide. Transactions must include all the information identified in the Implementation Guide as required information.

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Table of Contents

Introduction 5

References 5

Getting Started 6

Submitter EDI Enrollment 6

Connectivity Options to Se d and Receive Files 6

Ad inistrative Guidelines 6

Transaction Testing 7

Testing Steps 7

Testing Tips 8

Interchange Control and Functional Gr up Specs 10

Specific Data R quirements 11

Sa ple 837 Professional Transaction 20

Reporting 25

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Introduction This companion guide was developed for use in conjunction with the ASC X12N 837 Professional (004010X098A1) Implementation Guide. For any submission to MD On‐Line, Inc. (MDOL) if your transactions do not meet the specifications outlined in this guide, we may not be able to process those transactions. Additionally, claims must conform to provisions as set forth in any provider network contracts.

References a. ASC X12N Implementation Guide 004010X098, 004010X098A1

(Copies can be obtained from www.wpc‐edi.com)

b. Acronyms: � 837P ‐837 Professional Claim Transaction � ANSI – American National Standards Institute � ASC – Accredited Standards Committee � EDI – Electronic Data Interchange � GE – Functional Group Trailer � GS – Functional Group Header � HIPAA – Health Insurance Portability and Accountability Act of

1996 � IEA – Interchange Control Trailer � ISA – Interchange Control Header � MDOL – MD On‐Line � NDC ‐ National Drug Codes � NPI – National Provider Identification Number � ST‐ Tr nsaction Set Header � SE – T ansaction Set Trailer � X12 – The most widely used standard for EDI in the United States

http://www.wpc-edi.com/

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Getting Started MD On‐Line’s technology allows trading partners to submit claims check eligibility, receive claims status, and receive remittance advice and referrals. The MDOL network is easy to access and is based on HIPAA compliant standard transactions.

To get started, contact MDOL EDI Submitter Enrollment at 888‐499‐5465 for your Submitter Registration information and setup.

Submitter EDI Enrollment

Contact MDOL EDI Submitter Enrollment at 888‐499‐5465 for enrollment information.

Connectivity Options to Send and Receive Files

MD On‐Line offers EDI Submitter Trading Partners a web‐based file upload and report retrieval protocol. Contact MDOL EDI Submitter Enrollment at 888‐499‐ 5465 for more information.

Administrative Guidelines a. Each inbound transmission to MDOL should contain only one ISA/IEA

interchange. Within the ISA/IEA interchange, a trading partner may send multiple GS/GE functional groups. In turn, each GS/GE functional group may contain multiple ST/SE transaction sets.

b. Current J‐Codes (HCPCS) must be used in place of NDC codes. c. MDOL will not process negative alues. d. Claims that have more than seven characters in the dollar amount

segments will not be processed. (i.e. Amounts in excess of $99,999. not be processed.)

e. MDOL will not support file compression f. MDOL will only accept files that re formatted in uppercase

9 will

g. Until all payors request NPI only on claims, MDOL requests that legacy provider ID’s are submitted with NPI numbe s on claims.

h. When submitting provider tax ID’s, ID type (SSN or EIN) must match type enrolled in MDOL systems. If type is in question, please contact technical support at (888) 499‐5465.

i. If you are approved for 837 Professional claims production, any programming chang s to your software M ST be tested by MDOL prior

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to submitting claims from the changed software. Please contact technical support at (888) 499‐5465 to schedule testing.

j. Payor ID’s must be included in claims in the 2010BB segment. Please refer to the MDOL website at www.mdol.com for a complete list of payor ID’s.

Transaction Testing

MDOL will require testing with EDI Submitters before accepting production transmissions. EDI Submitters will receive all of the output reports that will be available in a production environment. For example, if a valid test claim file is submitted, they will receive:

� Communications Report � Functional Acknowledgement Report (997) � Claims Submission Validation Report(s).

Retesting is required if an EDI Submitter alters or upgrades their processing system as system changes may effect the production format.

MDOL reserves the right to temporarily revoke production status when an EDI Partner’s transactions repeatedly cause production errors. Production status would be re‐instated once retesting occurs and production errors are resolved.

Testing Steps

a. Once registration is complete, MDOL distributes a test submitter ID, secure password, and URL. The test submitter ID should be present in all test fil s in the ISA and GS segments.

b. The EDI Submitter creates test file (minimum of 10 transactions representative of types that will be submitted in production). For example, the test file contains 10 claims representing the various claim types submitted in the normal course of business such as chiropractic, anesthesia, and/or general office claims. It is important that valid patient used within the test file.

ata is

c. EDI Submitter will environment.

transmit the test file to MDOL’s test

d. EDI Submitter will review the test reports that MDOL provides:

i. Communication Report‐ verifies MDOL received the file

http://www.mdon-line.com/





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ii. The Claims Submission Validation Reports will indicate if the file passed internal edits. This report will show accepted and non‐accepted claims

e. EDI Submitter must correct all errors and resubmit the test files until these errors pass all edits. For assistance on these errors, please contact MDOL EDI Trading Partner Support 888‐499‐5465.

f. EDI Submitter must continue to make corrections and resubmit until the Not Accepted report shows zero claims present in the not accepted section of the report. For assistance with errors on the Not Accepted Report, please contact MDOL EDI Trading Partner Support 888‐499‐5465.

g. Once all test files are determined “clean” of errors, the Trading Partner must contact MDOL EDI Submitter Support at 888‐499‐5465 and an EDI representative will distribute a production submitter ID number production password.

and

NOTE: Test Transactions submitted to MDOL will NOT be Processed for Payment.

Testing T ips The following are tips and guidelines to assist in successful testing:

a) Check assignment of benefits to ensure that the appropriate indicator is

reflected for payments assigned to the provider.

b) Ensure that the billing, rendering, and referring provider numbers are valid and current.

c) If the EDI Submitter is submitting claims for clinic with several physicians cross‐

referenc d to it, ensure that the proper Tax ID, National Provider ID’s (NPI) and Legacy Provider IDs are valid and current.

d) Ensure that CPT4 codes used are valid and c service.

rrent for the associate type of

e) Ensure that a 3‐alpha prefix is present for all contract numbers, with the exception of federal contract numbers, which do not require this.

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837 Professional Claim Data Requirements

Files submitted to MDOL must comply with the Interchange and Application Control Structure Standards as shown in Appendix A of the adopted Implementation Guide for the 837 Professional Transaction X12N 4010 X098, X098A1.

Interchange Control Header and Trailer (ISA/IEA) Segments

The ISA segment is the only EDI segment that is fixed in length. The total number of positions in the ISA segment, including the letters “ISA”, is 106 bytes. MDOL utilizes the basic character set plus the ‘@’ sign from the extended character set as defined in the Implementation Guide.

The control number submitted in ISA13 must equal the control number in IEA02. The control numbers must always be unique on production files submitted to MDOL. Files with repeated control numbers will be rejected.

MDOL Required Delimiters and Terminators

Segment Delimiter ‘*’ Asterisk

Composite Element Delimiter ‘:’ Colon

Segment Terminator ‘~’ Tilde

Functional Group Header and Trailer (GS/GE) Segments

The Functional Group Header (GS) Segment indicates the beginning of a functional group of transaction sets. Please review Appendix A and B in the adopted Implementation Guide for the 837 Professional Transaction X12N 004010X for complete functional group header and trailer details.

98, X098A1

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Interchange Control and Functional Group Specs

Condition elements shown in the below table (R, S, O) refer to the field usage as listed in the adopted Implementation Guide for the 837 Professional Transaction X12N 4010 X098, X098A1. The usage conditions are:

• R = Required

• S = Situational

• = Optional

Loop ID /Segment

Element / Description Usag e

Condition R,S,O

Comments Acceptable Value

ISA INTERC ANGE CONTROL HEADER 1 FIXED RECORD LENGTH

SEGMENT (106 BYTES ONLY)

ISA01 – Authorization Info Qualifier

ISA02 – Authorization Information

ISA03 – Security Info Qualifier

ISA04 – Security Information

ISA05 – Interchange ID Qualifier

ISA06 – Interchange Sender ID

ISA07 – Interchange ID Qualifier

ISA08 – Interchange Receiver ID

ISA09 – Interchange Date

ISA10 – Interchange Time

ISA11 – Interchange Control Standards ID

ISA12 – Interchange Version Number

ISA13 – Interchange Control Number

ISA14 – Acknowledgement Requirement

ISA15 – Usage Indicator

ISA16 – Component Element Separator

GS FUNCTI NAL GROUP H ADER 1

GS01 – Functional ID Code

GS02 – Application Sender’s Code

GS03 – Application Receiver’s Code

GS04 – Date

GS05 – Time

GS06 – Group Control Number

GS07 – Responsible Agency Code

GS08 – Version/Release

GE FUNCTI NAL GROUP T AILER 1

GE01 – Number of Transaction Sets

GE02 – Group Control Number

IEA INTERC ANGE CONTROL TRAILER 1

IEA01 – Number of Functional Groups

IEA02 – Interchange Control Number

R

R 10 spaces

R

R 10 spaces

R R Submitter Tax ID (no

hyphen)

R

R

R YYMMDD Format

R HHMM Format

R

R

R Must Equal IEA02 R “1” or “0”

R (T) Test or (P) Production

R

R

R Submitter Tax ID (no hyphen)

R

R CCYYMMDD Format

R HHMM Format

R Must Equal GE02

R

R

R

R Must Equal GS06

R

R Must Equal ISA13

00

00

01, 14, 20, 27, 28, 29, 30, 33,

or ZZ

ZZ

ABILITY837

U

00401

:

HC

ABILITY837

X

004010X098A1

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N

H

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N

T

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Specific Data Requirements

Professional Claims (837P) Transaction Specs Loop ID

/Segment

Element / Description Usage Condition

R,S,O

Comme ts Acceptable

Value

ST TRANSACTION SET HEADER

ST01 – Transaction Set ID Code

ST02 – Transaction Set Control Number BHT BEGINNING OF HL TRA SACTION 1

BHT01 – Hierarchical Structure Code

BHT02 – Transaction Set Purpose Code

BHT03 – Reference ID

BHT04 – Date BHT05 – Time

BHT06 – Transaction Type Code

REF TRANS ISSION TYPE IDENTIFICATION 1

REF01 – Reference ID Qualifier

REF02 – Reference ID

R

R Must Equal SE02

R

R

R

R CCYYMMDD Format R HHMM Format

R

R

R

837

0019

00

CH

87

004010X098A1

LOOP 1000A

NM1

SUBMITTER INFO 1

SUBMITTER NAME 1

NM101 – Entity ID Code

NM102 – Entity Type Qualifier

R 41

R 1 For Person, 2 For Non‐Person Entity

LOOP 1000B

NM1

LOOP 2000A

HL

NM103 – Last Name/Organization Name

NM104 – First Name

NM105 – Middle Name

NM106 – Not Used NM107

– Name Suffix NM108 – ID

Code Qualifier NM109 – ID

Code

RECEIVER INFO 1

RECEIVER NAME 1




NM108 – ID Code Qualifier

NM109 – ID Code

BILLING PAY‐TO PROVIDER >1

Billing/Pay‐To Provider HL 1

HL01 – Hierarchical ID Number

HL02 – Not Used

HL03 – Hierarchical Level Code

HL04 – Hierarchical Child Code

R

R

R Submitter Tax ID (no hyphen)

R

R

R

R

R R

R Incremental

R

R

R

46

40

2

MDONLINE

46

223389595

20

1

12

C

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N

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r

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Professional Claims (837P) Transaction Specs

Loop ID /Segment

Element / Description Usage Condition R,S,O

Comme ts Acceptable Value

PRV BILLING PAY‐TO PROVIDER SPECIALITY

INFORMATION

PRV01 – Provider Code

PRV02 – Reference ID Qualifier ZZ

PRV03 – Taxonomy Code

LOOP 2010A NM1

BILLING PROVIDER INF

BILLING PROVIDER NA


RMATION 1

E 1

R 85

NM102 – Entity Type Qualifier R 1 For Person, 2 For Non‐Person Entity

N3

N4

REF

PER

LOOP 2000B

HL







Code

BILLING PROVIDER ADDRESS 1 N301 – Address1

N302 – Address2

BILLING PROVIDER CITY/ST/ZIP 1

N401 – City

N402 – State

N403 – Zip

N404 – Country BILLING PROVIDER SECONDARY ID 8



BILLING PROVIDER CONTACT 1 INFORMATION

PER01 – Contact Function Code

PER02 – Contact Name

PER03 – Communication Type Qualifier

PER04 – Communication Number

SUBSCRIBER >1

SUBSCRIBER HL 1

R

R

R

R

R

R

R

Required as per payer Specifications Required as per payer Specifications

R

HL01 – Hierarchical ID Number HL02 – Not Used



R Incremental R

R 22

R 0 If subscriber is the patient, 1 if subscriber

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A

C

C

N

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c

is not the patient



Loop ID /Segment



SBR

LOOP 2010BA

NM1

SUBSCRIBER INFORMATION 1

SBR01 – Payer Responsibility Sequence Number Code

SBR02 – Individual Relationship Code

SBR03 – Group or Policy Number

SBR04 – Group or Plan Name

SBR05 – Insurance Type Code

SBR09 – Claim Filing Indicator Code

SUBSCRIBER INFORMA ION

SUBSCRIBER NAME 1



R

R

R

R

R


CI, MB, or MC

IL

N3

N4

DMG

LOOP 2010BB

NM1







Code

SUBSCRIBER ADDRESS 1

N301 – Address1

N302 – Address2

SUBSCRIBER CITY/ST/ZIP 1

N401 – City

N402 – State

N403 – Zip

N404 – Country SUBSCRIBER DEMOGRAPHICS 1

DMG01 – Date/Time Qualifier

DMG02 – Subscriber Date of Birth DMG03 – Gender Code

PAYER 1

PAYER INFORMATION 1



NM103 – Payer Name NM108

– ID Code Qualifier NM109 –

R

R MI

R

R

R

R

R

D8

CCYYMMDD Format

R

R PR

R 2

R PI

Payer ID R Must use valid MDOL payer ID. For a copy of

14

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C

C

1

3

A

N

C



Loop ID /Segment



LOOP 2000C

HL

PAT

LOOP 2010CA

NM1

N3

N4

DMG

PATIENT

PATIENT HL

HL01 – Hierarchical ID Number

HL02 – Not Used



PATIENT

PAT01 – Individual Relationship Code

PATIENT INFORMATIO

PATIENT NAME



NM103 – Last Name

NM104 – First Name NM105 – Middle Name




Code PATIENT ADDRESS

N301 – Address1

N302 – Address2

PATIENT CITY/ST/ZIP

N401 – City

N402 – State

N403 – Zip

N404 – Country PATIENT

DEMOGRAPHICS DMG01 –

Date/Time Qualifier DMG02 –

Subscriber Date of Birth DMG03 –

Gender Code

1 Required if Subscriber is not Patient

1 Required if Subscriber

is not Patient Incremental

23

0

1

Required if Subscriber is not patient

1 Required if Subscriber is not Patient

1 R

R QC

R 1

R

R MI

R

1 R

1

R

R

R

1

D8

CCYYMMDD Format

LOOP 2300 CLAIM INFORMATION 100

CLM CLAIM DETAILS 1 R

CLM01 – Patient Account Number R

CLM02 – Total Claim Charge R

CLM05 – Place of Service Code R

CLM05‐1 – Facility Type Code R

CLM05‐3 – Claim Frequency Code R

CLM06 – Provider Signature Indicator R

CLM07 – Provider Accepts Assignment R

Code

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O

N

C

T

o

o

N

T

e



Loop ID /Segment



CLM CLAIM DETAILS CONTINUED

CLM08 – Benefits Assignment Certification Indicator

CLM09 – Release of Information Code

CLM10 – Patient Signature Source Code

CLM11 – Related Causes Code

CLM11‐1 –Related Causes Code



CLM11‐4 –Auto Accident State Code

CLM11‐5 –Country Code

CLM12 –Special Program Indicator

CLM16 –Provider Agreement Code

CLM20 –Delay Reason Code

DTP INITIAL REATMENT DATE 1

DTP01 –Date Qualifier

DTP02 –Date Format Qualifier

DTP03 –Delay Reason Code

R

R

S

R

S

S

S

S Required for Auto Accident Claims

S Required if Accident Occurred Outside of the United States

CCYYMMDD Format

454

D8

DTP DATE LAST SEEN 1




CCYYMMDD Format

304

D8

DTP ONSET F CURRENT ILLNESS DATE 1


DTP02 –Date Format Qualifier DTP03 –Delay

Reason Code SIMILAR ILLNESS/SYMPTOM DATE 1

CCYYMMDD Format

431

D8

DTP DTP01 –Date Qualifier DTP02 –Date Format Qualifier


CCYYMMDD Format

438

D8

DTP ACCIDE T DATE 1




CCYYMMDD Format

439

D8

CN1 CONTRA T INFORMATION 1

CN101 – Contract Type Code For claims involving case management, use code ’09 – Other’

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Loop ID /Segment



REF

HI

LOOP 2310A

CLAIM IDENTIFICATION NUMBER

REF01 – Claim ID Qualifier

REF02 – Number assigned by Sender

HEALTHCARE DIAGNOSIS CODE

HI01‐1 – Diagnosis Code Type

HI01‐2 – Principal Diagnosis Code


HI02‐2 – Diagnosis Code













REFERRING PROVIDER INFORMATION

D9

1

R BK

ICD‐9 Codes must be used

S BF


S BF


S BF


S BF


S BF


S BF


S BF


1

NM1 REFERRING PROVIDER


AME R DN

NM102 – Entity Type Qualifier R 1 For Person, 2 For Non‐Person En ity

NM103 – Last Name/Organization Name R





Code Qualifier NM109 – ID R

Code R

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–

R

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PRV REFERRING PROVIDER SPECIALITY 1 INFOR ATION

PRV01 – Provider Code PRV02 – RF

Reference ID Qualifier PRV03 – ZZ

Provider Taxonomy Code REFERRING

REF

LOOP 2310B NM1

PROVIDER SECONDARY ID REF01 – 5

Reference ID Qualifier


RENDERING PROVIDER INFORMATIO 1

RENDERING PROVIDER NAME







– Name Suffix NM108 – ID Code Qualifier NM109 – ID

Code


R 82


R

R R

Loo

/Seg

ID ent

Element / Description Usage R,S,O Comments Acceptable Value

PRV

REF

RENDERING PROVIDER SPECIALITY 1 INFORMATION

PRV01 – Provider Code PRV02 –

Reference ID Qualifier PRV03 –

Provider Taxonomy Code RENDERING PROVIDER SECONDARY ID 5 REF01 – Reference ID Qualifier


PE

ZZ Required as per payer Specifications Required as per payer Specifications

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S

N

C

N



LOOP 2310D

NM1

N3

N4

REF

LOOP 2330A

NM1

SERVICE FACILITY LOCATION

INFORMATION SERVICE FACILITY LOCATION NM101

– Entity ID Code NM102 – Entity Type Qualifier NM103

– Laboratory or Facility Name NM108

– ID Code Qualifier

NM109 – ID Code SERVICE FACILITY ADDRESS

N301 – Address1

N302 – Address2

SERVICE FACILITY CITY/ST/ZIP

N401 – City

N402 – State

N403 – Zip

N404 – Country

SERVICE FACILITY SECONDARY ID



OTHER SUBSCRIBER INFORMATION

PATIENT NAME



NM103 – Last Name

NM104 – First Name NM105 – Middle Name




Code

1

R Use code ‘77’ when

other codes in this element do not apply

R 2

R

R

R

1

R

1

R

R

R

5


1

1 R

R IL

R 1

R

R MI

R

LOOP 2320 OTHER SUBSCRIBER DEMOGRAPHIC 1 INFORMATION

DMG PATIENT DEMOGRAPHICS 1

DMG01 – Date/Time Qualifier

DMG02 – Subscriber Date of Birth DMG03 – Gender Code

Required when 2330A NM102 = ‘1’

D8

CCYYMMDD Format

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N

T

r



LOOP 2330B

OTHER AYER INFORM TION 1

NM1 PAYER INFORMATION 1 R

NM101 – Entity ID Code R PR

NM102 – Entity Type Qualifier R 2

NM103 – Payer Name

NM108 – ID Code Qualifier R PI

NM109 – Payer ID R

LOOP 2400 SERVICE LINE 50

LX

SV1

SERVICE LINE COUNTER LX01

– Service Line Counter

SERVICE LINE INFORMATION

SV101 – Procedure Identifier

SV101‐1 – Product or Services ID Qualifier

SV101‐2 – Procedure Code

SV101‐3 – Procedure Modifier

SV101‐4 – Procedure Modifier 2



SV102 – Line Item Charge

R

R

R

R

R

S

S

S

R Zero dollar charges are allowed as per specific payer requirements

DTP

SE

SV103 – Unit or Basis for Measurement

SV104 – Services Unit Count

SV105 – Place of Service Code

SV107‐1 – Diagnosis Code Pointer




SV109 – Emergency Indicator

SV111 – EPSDT Indicator

SV112 – Family Planning Indicator SV115 – Co‐Pay Status Indicator

SERVICE LINE DATE 15



DTP03 –Delay Reason Code TRANSACTION SET TRAILER

SE01 – Transaction Segment Count

R

R

R

R

S

S

S

S

S

S

S

Use RD8 to indicate To/From Range CCYYMMDD or CCYYMMDD‐ CCYYMMDD format

R

472

SE02 – Transaction Set Control Number R Must Equal ST02

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Sample 837 Professional Transaction

Patient is the same person as the Subscriber.

SUBSCRIBER/PATIENT: Ted Smith, ADDRESS:236 N. Main St., Miami, Fl, 33413, TELEPHONE NUMBER: 305‐555‐1111

SEX: M DOB: 05/01/43 EMPLOYER: ACME Inc. GROUP #: 12312‐A PAYER ID NUMBER: SSN SSN: 000‐22‐1111

DESTINATION PAYER: Alliance Health and Life Insurance Company (AHLIC), PAYOR ADDRESS: 2345 West Grand Blvd, Detroit, MI 48202. , AHLIC #: 741234

RECEIVER: MD On‐Line TAX ID #: 223389595

BILLING PROVIDER/SENDER: Premier Billing Service, ADDRESS: 234 Seaway St, Miami, FL, 33111 TIN: 587654321, EDI #: TGJ23 CONTACT PERSON AND PHONE NUMBER: JERRY, 305‐555‐2222 ext. 231

PAY‐TO PROVIDER: Kildare Associates, PROVIDER ADDRESS: 2345 Ocean Blvd, Miami, Fl 33111. PROVIDER ID: 9987 ‐ABA TIN: 581234567

RENDERING PROVIDER: Dr. Ben Kildare/Family AHLIC PROVIDER ID#: 9741234

ractitioner

PATIENT ACCOUNT NUMBER: 2‐646‐2967 CASE: Patient has sore throat.

INITIAL VISIT: DOS=10/03/98. POS=Office SERVICES: Office visit, intermediate service, established patient, throat culture. CHARGES: Office first visit = $40.00, Lab test for strep = $15.00

FOLLOW‐UP VISIT: DOS=10/10/98 POS=Office Antibiotics didn’t work (pain continues). SERVICES: Office visit, intermediate service, established patient, mono screening. CHARGES: Follow‐u visit = $35.00, lab test for mono = $10.00.

TOTAL CHARGES: $ 00.00.

21

B

B

0

P

P

0

2

P

L R A R * R

E ~

D C

N

4

TRANSACTION SET HEADER

ST*837*0021~ BHT BEGINNING OF HIERARCHICAL TRANSACTION BHT*0019*00*0123*19981015*1023*CH~

REF TRANSMISSION TYPE IDENTIFICATION REF*87*004010X098A1~

1000A SUBMITTER

NM1 SUBMITTER NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~

PER SUBMITTER EDI CONTACT INFORMATION PER*IC*JERRY*TE*3055552222*EX*231~

1000B RECEIVER

NM1 RECEIVER NAME NM1*40*2*MD ON-LINE*****46*223389595~

2000A BILLING/PAY-TO PROVIDER HL LOOP

HL-BILLING PROVIDER HL*1**20*1~

2010AA BILLING PROVIDER

NM1 BILLING PROVIDER NAME NM1*85*2*PREMIER BILLING SERVICE*****24*587654321~

N3 BILLING PROVIDER ADDRESS N3*234 SEAWAY ST~

N4 BILLING PROVIDER LOCATION N4*MIAMI*FL*33111~

2010AB PAY-TO PROVIDER

NM1 PAY-TO PROVIDER NAME NM1*87*2*KILDARE ASSOC*****24*581234567~

N3 PAY-TO PROVIDER ADDRESS N3*2345 OCEAN BLVD~

N4 PAY-TO PROVIDER CITY N4*MIAMI*FL*33111~

2000B SUBSCRIBER HL

HL-SUBSCRIBER

HL*2*1*22*0~

LOOP

22

H

0

* * 2

G 5 A B

R

N 0

C

L F A

N ~

V D

N D Y

I

1 R

O *

4

D

SBR SUBSCRIBER INFORMATION SBR*P*18*12312-A******HM~

2010BA SUBSCRIBER NM1 SUBSCRIBER NAME

NM1*IL*1*SMITH*TED****MI*000221111~ N3 SUBSCRIBER ADDRESS N3*236 N MAIN ST~

N4 SUBSCRIBER CITY N4*MIAMI*FL*33413~

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION DMG*D8*19430501*M~

2010BB SUBSCRIBER/PAYER

NM1 PAYER NAME NM1*PR*2*ALLIANCE HEALTH AND LIFE INSURANCE*****PI*741234~

2300 CLAIM

CLM CLAIM LEVEL INFORMATION CLM*26462967*100***11::1*Y*A*Y*Y*C~

DTP DATE OF ONSET DTP*431*D8*19981003~

REF CLEARING HOUSE CLAIM NUMBER (Added by MDOL) REF*D9*123456789~

HI HEALTH CARE DIAGNOSIS CODES HI*BK:0340*BF:V7389~

2310B RENDERING PROVIDER

NM1 RENDERING PROVIDER NAME NM1*82*1*KILDARE*BEN****34*112233334~

PRV RENDERING PROVIDER INFORMATION PRV*PE*ZZ*203BF0100Y~

2310D SERVICE LOCATION

NM1 SERVICE FACILITY LOCATION NM1*77*2*KILDARE ASSOCIATES*****24*581234567~

N3 SERVICE FACILITY ADDRESS N3*2345 OCEAN BLVD~

23

*

S

* I

4

S 1 E

L

I 3 I

R 1 D ~

~ ~

N4 SERVICE FACILITY CITY/STATE/ZIP N4*MIAMI*FL*33111~

2400 SERVICE LINE

LX SERVICE LINE COUNTER LX*1~

SV1 PROFESSIONAL SERVICE SV1*HC:99213*40*UN*1***1**N~

DTP DATE - SERVICE DATE(S) DTP*472*D8*19981003~

2400 SERVICE LINE




2400 SERVICE LINE




2400 SERVICE LINE




TRAILER

SE TRANSACTION SET TRAILER

SE*42*0021~

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Complete data string:

ST*837*0021~BHT*0019*00*0123*19981015*1023*RP~REF*87*004010X 098~NM1*41*2*PREMIER BILLING SERVICE** ***46*TGJ23~PER*IC*JERRY*TE*3055552222*EX*231~NM1* 40*2*MD ON-LINE*****46*223389595~HL*1**20*1~NM1* 85*2*PREMIER BILLING SERVICE*****24*587654321~N3* 234 SEAWAY ST~N4*MIAMI*FL*33111~NM1*87*2*KILDARE ASSOC*****24*581234567~N3*2345 OCEAN BLVD~N4*MIAMI *FL*33111~HL*2*1*22*0~SBR*P*18*12312-A******HM~NM1 *IL*1*SMITH*TED****34*000221111~N3*236 N MAIN ST~ N4*MIAMI*FL*33413~DMG*D8*19430501*M~NM1*PR*2* ALLIANCE HEALTH AND LIFE INSURANCE*****PI*741234~ CLM*26462967*100***11::1*Y*A*Y*Y*C~DTP*431*D8* 19981003~REF*D9*123456789~HI*BK:0340*BF:V7389~NM1* 82*1*KILDARE*BEN****34*112233334~PRV*PE*ZZ*203BF0100Y~ NM1*77*2*KILDARE ASSOCIATES*****24*581234567~N3*2345 OCEAN BLVD~N4*MIAMI*FL*33111~LX*1~SV1*HC:99213*40*UN*1***1**N~DTP* 472*D8*19981003~LX*2~SV1*HC:87072*15*UN*1***1**N~DTP*472* D8*19981003~LX*3~SV1*HC:99214*35*UN*1***2**N~DTP*472*D8*1998 1010~LX*4~SV1*HC:86663*10*UN*1***2**N~DTP*472*D8*19981010~SE *42*0021~

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Reporting

EDI Submitter Production reports include:

a. Communication Report‐ verifies MDOL received the file (Human

Readable)

b. The Claims Submission Validation Reports will indicate if the file

passed internal edits. This report accepted claims (Human Readable)

will show accepted and non‐

837 Professional Claims Standard Companion Guide for ... · pr odu ct ion). F exam l , h est file...

Documents

Transcript of 837 Professional Claims Standard Companion Guide for ... · pr odu ct ion). F exam l , h est file...