Vendor Specifications 837 Institutional Claim ASC X12N ... Companion Guides... · Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010 Last Updated: 09/19/2019 Page 1 of

Vendor Specifications

837 Institutional Claim

ASC X12N Version 005010X223A2

for

State of Idaho MMIS

Date of Publication: 09/19/2019

Document Number: TL426

Version: 10.0

Idaho MMIS IDMedicaid.com Welcome Guide

Last Updated: 09/19/2019 Page ii

Revision History

Version Date Author Action/Summary of Changes

1.0 07/01/2011 Molina Initial document

1.1 12/21/2011 Eric Harvey Added the HI01-1 and HI02-2 segments in loop

2300

2.0 01/05/2012 TQD Promoted to next whole version

2.1 06/18/2012 Alisa Nicolls Updated the 2010BA loop NM109 segment with

approved language per 10 digit MID

3.0 06/19/2012 TQD Promoted to the next whole version

3.1 04/22/2014 M McFadden Added ICD-10 references

Reviewed and brought up to current standards

3.2 07/31/2014 M McFadden Edifecs 8.3 Upgrade (CCF 10735B1) changes

3.3 8/7/2014 Megan Lloyd Updated the document based on Cindy Day’s

feedback related to CCF 10735B1.

4.0 8/15/2014 TQD DHW validated 8/15/14

4.1 8/20/2014 M McFadden Corrected value for Segment PRV01


5.1 5/21/2015 M McFadden Semi-annual review performed – made changes


6.1 12/15/2015 Cathy Butler Semi-annual changes

7.0 1/25/2016 TQD DHW validated changes 1/22/16

7.1 5/26/2016 Douglas

Greer

Semi-annual review – changes made

8.0 6/16/2016 TQD DHW validated changes 6/10/16

8.0 3/21/2017 Cathy Butler Semi-annual review; no updates necessary.

8.0 6/8/2017 J Phillips Semi-annual review – no updates necessary.

8.1 10/24/2017 D Greer Added the rendering and referring physician loops

at both the claim and service line levels for CR

51973.

9.0 12/8/2017 TQD DHW validated changes 10/27/2017.

9.0 06/20/2018 Cathy Butler Semi-annual review; no updates necessary.

9.0 10/5/2018 M Zampierin Removed all Molina references and replaced with

DXC Technology

9.0 11/27/2018 Cathy

Lavacchia

Semi-annual review; no updates necessary.

9.0 1/11/2019 M Zampierin Updated Copyright statement to DXC

9.1 8/26/2019 J Phillips Updated for CCF 10760B3

10.0 09/19/2019 TQD Finalized – DHW validated changes 09/06/19

10.0 11/27/2019 Douglas

Greer

Semi-annual review; no updates necessary.

© 2018-2019 DXC Technology Company. All rights reserved. -

http://www.dxc.technology/legal

Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010

Last Updated: 09/19/2019 Page iii

Table of Contents

1. Companion Guide Purpose ..................................................................................... 1

1.1. Required Information ..................................................................................... 1

1.2. Trading Partner ID ......................................................................................... 1

1.3. Delimiters ..................................................................................................... 2

1.4. Additional Information .................................................................................... 2

2. 837 Institutional Claim.......................................................................................... 3

Appendix A. ............................................................................................................. 47

Table of Figures

Figure 2-1: 837 Institutional Claim ............................................................................... 3


Last Updated: 09/19/2019 Page 1 of 47

1. Companion Guide Purpose This companion guide documents the transaction type listed below and further defines

situational and required data elements that are used for processing claims for programs

administered by the Idaho Medicaid. This document is not the complete EDI transaction

format specifications.

Please refer to the 5010A2 Technical Report Type 3 for information not supplied in this

document, such as code lists, definitions, and edits.

Health Care Claim: Institutional 005010X223 May 2006

Health Care Claim: Institutional 005010X223A1 October 2007

Health Care Claim: Institutional 005010X223A2 June 2010

For any questions or to begin testing, please contact the DXC Technology EDI Helpdesk at

1 (866) 686-4272 and ask for Technical Support or e-mail DXC Technology at

[email protected].

1.1. Required Information Data elements, segments, and loops not included in this guide are not used for processing

claims by Idaho Medicaid, but must still be sent if the information is required for compliance

with the ASC X12N version 5010A2 format.

1.2. Trading Partner ID A trading partner is defined as any entity with which DXC Technology exchanges electronic

data. The term electronic data is not limited to HIPAA X12 transactions. Idaho Medicaid’s

Health PAS system supports the following categories of trading partner:

Provider

Billing Agency

Clearinghouse

Health Plan

DXC Technology will assign trading partner IDs to support the exchange of X12 EDI

transactions for providers, billing agencies and clearinghouses, and other health plans.

All trading partners must be authorized to submit production EDI transactions. Any trading

partner may submit test EDI transactions. Trading partners must have a “T” in ISA15 in all

submitted test files. Authorization is granted on a per transaction basis. For example, a

trading partner may be certified to submit 837P professional claims but not certified to

submit 837I institutional claim files.

Trading partners must submit three test files of a particular transaction type, with a

minimum of 15 transactions within each file, and have no failures or rejections in order to

become certified for production. Users will be notified via e-mail and the Trading Partner

Status page of Health PAS-Online when testing for a particular transaction has been

completed.

Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may

be found in Appendix A of this document.

To obtain a trading partner ID, please visit the website at www.idmedicaid.com or contact

DXC Technology at 1 (866) 686-4272, and choose option 2.

mailto:[email protected]

http://www.idmedicaid.com/



1.3. Delimiters Idaho Medicaid does not require the use of specific values for the delimiters used in

electronic transactions. The suggested values are included in the specifications below.

1.4. Additional Information Please refer to the industry 5010A2 Technical Report Type 3 (also known as the TR3 Guide)

for information not supplied in this document, such as code lists, definitions, and edits.



2. 837 Institutional Claim Figure 2-1: 837 Institutional Claim

Loop Segment

ID

Segment Name/ Data

Element Name

Format Length DE Ref

#

Req Des. Value

HEADER ISA Interchange Control

Header

3 R ISA

Element Separator AN 1 *

ISA01 Authorization

Information Qualifier

ID 2 I01 R 00


ISA02 Authorization

Information

AN 10 I02 R Space fill


ISA03 Security Information

Qualifier

ID 2 I03 R 00


ISA04 Security Information AN 10 I04 R Space fill


ISA05 Interchange ID Qualifier ID 2 I05 R ZZ


ISA06 Interchange Sender ID AN 15 I06 R Molina assigned

trading partner ID + 3

spaces. i.e.

IDTPID000001 + 3

spaces


ISA07 Interchange ID Qualifier ID 2 I05 R ZZ


ISA08 Interchange Receiver ID AN 15 I07 R ID_MMIS_4MOLINA


ISA09 Interchange Date DT 6 I08 R YYMMDD


ISA10 Interchange Time TM 4 I09 R HHMM



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value


ISA11 Interchange Control ID ID 1 I10 R ^


ISA12 Interchange Version

Number

ID 5 I11 R 00501


ISA13 Interchange Control

Number

N0 9 I12 R Must be identical to

the interchange trailer

IEA02 (defined by

sending Trading

Partner)


ISA14 Ack. Requested ID 1 I13 R 1 (Interchange

acknowledgement

requested)


ISA15 Usage Indicator ID 1 I14 R P or T (Must contain a

“P” indicator in

production)


ISA16 Component Element

Separator

1 I15 R :

Segment End B 1 ~

GS Functional Group

Header

2 R GS


GS01 Functional Identifier

Code

ID 2 479 R HC


GS02 Application Sender's

Code

AN 2/15 142 R Molina assigned

trading partner ID


GS03 Application Receiver's

Code

AN 15 124 R ID_MMIS_4MOLINA



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value


GS04 Date DT 8 373 R CCYYMMDD


GS05 Time TM 4/8 337 R HHMM


GS06 Group Control Number N0 1/9 28 R Assigned by Sender


GS07 Responsible Agency

Code

ID 1/2 455 R X


GS08 Version / Release Code AN 12 480 R 005010X223A2

Segment End B 1 ~

ST Transaction Set Header 2 R ST


ST01 Transaction Set

Identifier Code

ID 3 143 R 837


ST02 Transaction Set Control

Number

AN 4/9 329 R Sequential number

assigned by sender ST

and SE must be

equivalent

Segment End B 1 ~

ST03 Technical Report Type 3

Version Name

AN 35 R 005010X223A2

BHT Beginning Hierarchical

Transaction Segment

ID 3 R BHT


BHT01 Hierarchical Structure

Code

ID 4 1005 R 0019


BHT02 Transaction Set Purpose

Code

ID 2 353 R ‘00’ Original


BHT03 Reference identification AN 1/30 127 R Submitter Transaction



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Identifier


BHT04 Date DT 8 373 R CCYYMMDD


BHT05 Time TM 4/8 337 R HHMM


BHT06 Transaction Type Code ID 2 640 R CH = Chargeable

RP = Reporting (used

for encounters)

Segment End B 1 ~

1000A NM1 Submitter Name ID 3 R NM1


NM101 Entity Identifier Code ID 2/3 98 R 41


NM102 Entity Type Qualifier ID 1 1065 R 1 or 2


NM103 Name Last or

Organization Name

AN 1/60 1035 R


NM104 Name First AN 1/35 1036 S


NM105 Name Middle AN 1 1037 S


NM108 Identification Code

Qualifier

ID 1/2 66 R 46


NM109 Identification Code AN 2/80 67 R Trading Partner ID

Segment End B 1 ~

1000A PER Submitter EDI Contact

Information

ID 3 R PER


PER01 Contact Function Code ID 2/2 366 R IC




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

PER02 Name AN 1/60 93 R


PER03 Communication Number

Qualifier

ID 2/2 365 R TE = Telephone


PER04 Communication Number AN 1/256 364 R

Segment End B 1 ~

1000B NM1 Receiver Name ID 3 R NM1




NM102 Entity Type Qualifier ID 1 1065 R 2


NM103 Name Last or

Organization Name

AN 60 1035 R ID_MMIS_4MOLINA



Qualifier

ID 1/2 66 R 46


NM109 Identification Code AN 80 67 R ID_MMIS_4MOLINA

Segment End B 1 ~

2000A HL Billing/Pay-to Provider

Hierarchical Level

ID 2 R HL


HL01 Hierarchical ID Number AN 1 628 R 1



HL03 Hierarchical Level Code ID 1/2 735 R 20


HL04 Hierarchical Child Code ID 1/1 736 R 1

Segment End B 1 ~

2000A PRV Billing/Pay-to Provider

Specialty Information

ID 3 S PRV



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value


PRV01 Provider Code ID 1/3 1221 R BI = Billing


PRV02 Reference Identification

Qualifier

ID 2/3 128 R PXC


PRV03 Reference Identification AN 1/50 127 R Provider Taxonomy

Code

Segment End B 1 ~

2010AA NM1 Billing Provider Name ID 3 R NM1






NM103 Name Last or

Organization Name

AN 1/60 1035 R







Qualifier

ID 1/2 66 S XX = National

Provider ID (NPI)


NM109 Identification Code AN 2/80 67 S NPI

Segment End B 1 ~

2010AA N3 Billing Provider Address ID 2 R N3


N301 Address Information AN 1/55 166 R


N302 Address Information AN 1/55 166 S Required if a second

address line exists.



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Segment End B 1 ~

2010AA N4 Billing Provider

City/State/Zip Code

ID 2 R N4


N401 City Name AN 2/30 19 R


N402 State or Province Code ID 2 156 R


N403 Postal Code ID 5/15 116 R

Segment End B 1 ~

2010AA REF Billing Provider

Secondary Identification

Number

ID 3 R


REF01 Reference Identification

Qualifier

ID 2/3 128 R EI = Employer’s

Identification Number Element Separator AN 1 *

REF02 Reference Identification ID 1/50 127 R

Segment End B 1 ~

2000B HL Subscriber Hierarchical

Level

ID 2 R HL


HL01 Hierarchical ID Number AN 1 628 R 2


HL02 Hierarchical Parent ID

Number

AN 1/12 734 R


HL03 Hierarchical Level Code ID 1/2 735 R 22


HL04 Hierarchical Child Code ID 1 736 R 0

Segment End B 1 ~

2000B SBR Subscriber Information ID 3 R SBR




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

SBR01 Payer Responsibility

Sequence Number Code

ID 1 1138 R P, S or T


SBR02 Individual Relationship

Code

ID 2 1069 S 18


SBR03 Reference Identification AN 1/50 127 S


SBR04 Name AN 1/60 93 S






SBR09 Claim Filing Indicator

Code

ID 1/2 1032 S MC = Medicaid

Segment End B 1 ~

2010BA NM1 Subscriber Name ID 3 R NM1


NM101 Entity Identifier Code ID 2/3 98 R IL


NM102 Entity Type Qualifier ID 1 1065 R 1 = Person


NM103 Name Last or

Organization Name

AN 1/60 1035 R




NM105 Name Middle AN 1/25 1037 S



NM107 Name Suffix AN 1/10 1039 S




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value


Qualifier

ID 1/2 66 R MI = Member

Identification Number


NM109 Identification Code AN 7/10 67 R Enter the Idaho

Medicaid participant’s

10 digit identification

number. Always add

leading zeroes to

make a total of 10

digits if the

participant’s ID card

reflects 7 digits.

Segment End B 1 ~

2010BA N3 Subscriber Address ID 2 R N3




N302 Address Information AN 1/55 166 S

Segment End B 1 ~

2010BA N4 Subscriber

City/State/Zip Code

ID 2 R N4


N401 City Name AN 2/30 19 R


N402 State or Province Code ID 2 156 R


N403 Postal Code ID 5/15 116 R

Segment End B 1 ~

2010BA DMG Demographic

Information

ID 3 DMG


DMG01 Date Time Period

Format Qualifier

ID 2/3 1250 D8




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

DMG02 Date Time Period AN 1/35 1251 Date of birth

CCYYMMDD


DMG03 Gender Code ID 1/1 1068 M=Male

F=Female

U=Unknown

Segment End B 1 ~

2010BB NM1 Payer Name ID 3 R NM1


NM101 Entity Identifier Code ID 2/3 98 R PR




NM103 Name Last or

Organization

AN 1/60 1035 R ID_MMIS_4MOLINA







Qualifier

ID 1/2 66 R PI = Payer

Identification


NM109 Identification Code AN 2/80 67 R ID_MMIS_4MOLINA

Segment End B 1 ~

REF Billing Provider


ID 3 S REF



Qualifier

ID 2/3 R G2


REF02 Reference Identification AN 1/50 R Provider Medicaid ID

(Atypical Providers)

Segment End B 1 ~



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

2300 CLM Claim Information ID 3 R CLM


CLM01 Claim Submitter’s

Identifier

AN (1/20) 1028 R


CLM02 Monetary Amount R 1/18 782 R




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

Component Element

Separator

AN 1 :

CLM05-2 Facility Code Qualifier AN 1/2 1332 R A

Component Element

Separator

AN 1 :

CLM05-3 Claim Frequency Type

Code

ID 1 1325 R Valid codes are 0 – 9



CLM07 Provider Accept

Assignment Code

ID 1/1 1359 O


CLM08 Yes/No Condition or

Response Code

ID 1 1073 R Y


CLM09 Release of Information

Code

ID 1 1363 R Y










Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value





CLM20 Delay Reason Code ID 1/2 1514 S

Segment End B 1 ~

2300 DTP Discharge Hour

Note: Segment cannot

be used if claim is

outpatient or claim is

inpatient and CLM05-03

is 2 or 3.

ID 3 S DTP


DTP01 Date/Time Qualifier ID 3 374 R 096


DTP02 Date Time Period

Format Qualifier

ID 2/3 1250 R TM


DTP03 Date Time Period AN 1/35 1251 R HHMM

Segment End B 1 ~

2300 DTP Statement Dates ID 3 R DTP





Format Qualifier

ID 2/3 1250 R RD8


DTP03 Date Time Period AN 1/35 1251 R CCYYMMDD-

CCYYMMDD

Segment End B 1 ~

2300 DTP Admission Date/Hour ID 3 S DTP






Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value


Format Qualifier

ID 2/3 1250 R DT


DTP03 Date Time Period AN 1/35 1251 R CCYYMMDDHHMM

Segment End B 1 ~

2300 CL1 Institutional Claim Code ID 3 R CL1


CL101 Priority (Type) of

Admission or Visit

ID 1 1315 R


CL102 Point of Origin for

Admission or Visit

ID 1 1314 S


CL103 Patient Status Code ID 1/2 1352 S If = 20, 40, 41 or 42

then 2300\HI

Occurrence

Information should be

used with code 55 in

HIxx-02 (date of

death)

Segment End B 1 ~

2300 REF Original Reference

Number (ICN/DCN)

ID 3 S REF



Qualifier

ID 2/3 128 R 9F = Referral


REF02 Reference Identification AN 1/50 127 R Original ICN

Segment End B 1 ~

2300 REF Prior Authorization ID 3 S REF Element Separator AN 1 *


Qualifier

ID 2/3 128 R G1 = Prior

Authorization Number




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

REF02 Reference Identification AN 1/50 127 R Assigned Prior

Authorization Number

Segment End B 1 ~

2300 REF Referral Number ID 3 S REF



Qualifier

ID 2/3 128 R F8 = Original

Reference Number


REF02 Reference Identification AN 1/50 127 R

Segment End B 1 ~

2300 REF Medical Record Number ID 3 S REF



Qualifier

ID 2/3 128 R EA


REF02 Reference Identification AN 1/50 127 R

Segment End B 1 ~

2300 HI Principal Diagnosis

Information

ID 2 S HI


HI01-1 Code List Qualifier Code ID 1/3 1270 R BK (ICD-9) – Principal

Diagnosis

ABK (ICD-10) –

Principal Diagnosis

Component Element

Separator

1 :

HI01-2 Industry Code AN 1/30 1271 R Principal Diagnosis

Code

Note: Cannot be

External Cause Code

Component Element

Separators (for ‘not

used’ elements)

AN 1 :::::::

HI01-9 Present on Admission ID 1 1073



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Indicator

Segment End B 1 ~

2300 HI Admitting Diagnosis

Information

ID 2 S HI


HI01-1 Code List Qualifier Code ID 1/3 1270 R BJ (ICD-9) –

Admitting Diagnosis

ABJ (ICD-10) –

Admitting Diagnosis

Component Element

Separator

1 :

HI01-2 Industry Code AN 1/30 1271 R Admitting Diagnosis

Code

Component Element


used’ elements)

AN 1 :::::::

HI01-9 Present on Admission

Indicator

ID 1 1073

Segment End B 1 ~

2300 HI Patient Reason for Visit

Diagnosis Information

ID 2 S HI


HI01-1 Code List Qualifier Code ID 1/3 1270 R PR (ICD-9) – Patient

Reason

APR (ICD-10) –

Patient Reason

Component Element

Separator

1 :

HI01-2 Industry Code AN 1/30 1271 R Patient Reason for

Visit Diagnosis Code –

must be unique within

the Claim

Component Element


AN 1 :::::::



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

used’ elements)


Indicator

ID 1 1073

Note: Can be up to 3

HI0x-1 thru HI0x-9

elements separated

by *

Segment End B 1 ~

2300 HI External Cause of Injury

Diagnosis Information

ID 2 S HI


HI01-1 Code List Qualifier Code ID 1/3 1270 R BN (ICD-9) – External

Cause of Injury

ABN (ICD-10) –

External Cause of

Injury

Component Element

Separator

1 :

HI01-2 Industry Code AN 1/30 1271 R External Cause of

Injury Diagnosis Code

Component Element


used’ elements)

AN 1 :::::::


Indicator

ID 1 1073


HI0x-1 thru HI0x-9

elements separated

by *

Segment End B 1 ~

2300 HI Other Diagnosis

Information

ID 2 S HI


HI01-1 Code List Qualifier Code ID 1/3 1270 R BF (ICD-9) – Other



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Diagnosis

ABF (ICD-10) – Other

Diagnosis

Component Element

Separator

1 :

HI01-2 Industry Code AN 1/30 1271 R Other Diagnosis Code

Component Element


used’ elements)

AN 1 :::::::


Indicator

ID 1 1073


HI0x-1 thru HI0x-9

elements separated

by *

Segment End B 1 ~

2300 HI Principal Procedure

Information

ID 2 S HI


HI01-1 Code List Qualifier Code ID 1/3 1270 R BR (ICD-9) – Principal

Procedure

BBR (ICD-10) –

Principal Procedure

Component Element

Separator

1 :

HI01-2 Industry Code AN 1/30 1271 R Principal Procedure

Code

Component Element

Separator

1 :

HI01-3 Date Time Period

Format Qualifier

ID 2/3 1250 S D8

Component Element

Separator

1 :

HI01-4 Date Time Period AN 1/35 1251 S CCYYMMDD



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Segment End B 1 ~

2300 HI Other Procedure

Information

ID 2 S HI


HI01-1 Code List Qualifier Code ID 1/3 1270 R BQ (ICD-9) – Other

Procedure

BBQ (ICD-10) – Other

Procedure

Component Element

Separator

1 :

HI01-2 Industry Code AN 1/30 1271 R Other Procedure Code

Component Element

Separator

1 :


Format Qualifier

ID 2/3 1250 S D8

Component Element

Separator

1 :

HI01-4 Date Time Period AN 1/35 1251 S CCYYMMDD



HI0x-1 through HI0x-

4 elements separated

by *

Segment End B 1 ~

2300 HI Occurrence Span

Information

ID 2 S HI


HI01-1 Code List Qualifier Code ID 1/3 1270 R BI – Occurrence Span

Component Element

Separator

1 :

HI01-2 Industry Code AN 1/30 1271 R Occurrence Span code

Component Element

Separator

1 :

HI01-3 Date Time Period ID 2/3 1250 S RD8



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Format Qualifier

Component Element

Separator

1 :

HI01-4 Date Time Period AN 1/35 1251 S CCYYMMDD-

CCYYMMDD




by *

Segment End B 1 ~

2300 HI Occurrence Information ID 2 S HI


HI01-1 Code List Qualifier Code ID 1/3 1270 R BH – Occurrence Code

Component Element

Separator

1 :

HI01-2 Industry Code AN 1/30 1271 R Occurrence Code

Note: must be 55

(date of death) when

CL103 is one of 20,

40, 41 or 42.

Component Element

Separator

1 :


Format Qualifier

ID 2/3 1250 R D8

Component Element

Separator

1 :

HI01-4 Date Time Period AN 1/35 1251 R CCYYMMDD




by *

Segment End B 1 ~

2300 HI Value Information

Codes

ID 2 S HI



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value


HI01-1 Code List Qualifier Code ID 1/3 1270 R BE – Value Code

Component Element

Separator

1 :

HI01-2 Industry Code AN 1/30 1271 R Value Code




by *

Segment End B 1 ~

2300 HI Condition Information ID 2 S HI


HI01-1 Code List Qualifier Code ID 1/3 1270 R BG – Condition Code

Component Element

Separator

1 :

HI01-2 Industry Code AN 1/30 1271 R Condition Code




by *

Segment End B 1 ~

2310A NM1 Attending Physician

Name

ID 3 S NM1




NM102 Entity Type Qualifier ID 1 1065 R 1 – Person


NM103 Name Last or

Organization Name

AN 1/60 1035 R







Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value




Qualifier

ID 1/2 66 S XX = National

Provider ID (NPI)


NM109 Identification Code AN 2/80 67 S NPI

Segment End B 1 ~

2310A PRV Attending Physician

Specialty Information

ID 3 S PRV


PRV01 Provider Code ID 1/3 1221 R AT


PRV02 Reference Identification

Qualifier

ID 2/3 128 R PXC


PRV03 Reference Identification AN 1/50 127 R Provider Taxonomy

Code

Segment End B 1 ~

2310A REF Attending Physician


ID 3 S REF



Qualifier

ID 2/3 128 R EI = Employer’s

Identification Number

G2= Provider

Medicaid ID


REF02 Reference Identification AN 1/50 127 R EIN or Provider

Medicaid ID

Segment End B 1 ~

2310B NM1 Operating Physician

Name

ID 3 S NM1





Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value


NM102 Entity Type Qualifier ID 1 1065 R 1 - person


NM103 Name Last or

Organization Name

AN 1/60 1035 R


NM104 Name First AN 1/35 1036 R







Qualifier

AN 2 XX = National

Provider ID (NPI)


NM109 Identification Code AN 2/80 R NPI

Segment End B 1 ~

2310B REF Operating Physician


ID 3 S REF



Qualifier

ID 2/3 R G2 = Provider

Medicaid ID


REF02 Reference Identification AN 1/50 127 R Provider Medicaid ID

Segment End B 1 ~

2310C NM1 Other Operating

Physician Name

ID 3 S NM1


NM101 Entity Identifier Code ID 2/3 98 R ZZ


NM102 Entity Type Qualifier ID 1 1065 R 1 – person


NM103 Name Last or AN 1/60 1035 R



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Organization Name









Qualifier

ID 1/2 66 R XX=National Provider

ID (NPI)


NM109 Identification Code AN 2/80 67 R NPI

Segment End B 1 ~

2310C REF Other Provider


ID 3 S REF



Qualifier

ID 2/3 128 R EI = EIN

G2 = Provider

Medicaid ID


REF02 Reference Identification AN 1/50 127 R EIN or Provider

Medicaid ID

Segment End B 1 ~

2310D NM1 Rendering Physician

Name

ID 3 S NM1






NM103 Name Last or

Organization Name

AN 1/60 1035 R





Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value







Qualifier


ID (NPI)



Segment End B 1 ~

2310D REF Rendering Secondary

Identification

ID 3 S REF



Qualifier

ID 2/3 128 R G2 = Provider

Medicaid ID



Segment End B 1 ~

2310E NM1 Service Facility Name ID 3 S NM1






NM103 Name Last or

Organization Name

AN 1/60 1035 R Service Location

Name







Qualifier

AN ½ 66 S XX=National Provider

ID (NPI)



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value


NM109 Identification Code AN 2/80 67 S NPI - do not send if

same as for Billing

Provider

Segment End B 1 ~

2310E N3 Service Facility Location

Address

S N3



N302 Address Information AN 1/55 167 S

Segment End B 1 ~

2310E N4 Service Facility

City/State/Zip

ID 2 N4

N401 City AN 2/30 19 R


N402 State ID 2 156 R


N403 Zip Code AN 3/15 116 R

Segment End B 1 ~

2310E REF Service Facility


ID 3 S REF



Qualifier

ID 2/3 128 R LU


REF02 Reference Identification AN 1/50 127 R Service Location

Identifier

Segment End B 1 ~

2310F NM1 Referring Physician

Name

ID 3 S NM1


NM101 Entity Identifier Code ID 2/3 98 R DN





Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value


NM103 Name Last or

Organization Name

AN 1/60 1035 R









Qualifier


ID (NPI)



Segment End B 1 ~

2310F REF Referring Provider


ID 3 S REF



Qualifier


Medicaid ID



Segment End B 1 ~

** for Medicare COB

information the

following segments are

required **

2320 SBR Other Subscriber

Information

ID 3 S SBR




ID 1 1138 R P


SBR02 Individual Relationship ID 2 1069 R 18



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Code


SBR03 Reference Identification AN 1/50 127 S Insured Group or

Policy Number


SBR04 Name AN 1/60 93 S MEDICARE







Code

ID 1/2 1032 S MA

Segment End B 1 ~

2320 CAS Claim Level

Adjustments

ID 3 S CAS


CAS01 Claim Adjustment

Group Code

ID 1/2 1033 R PR



Reason Code

ID 1/5 1034 R 1 - for Medicare

Deductible


CAS03 Monetary Amount R 1/18 782 R Medicare Deductible

Amount


CAS04 Quantity R 1/15 380 S



Reason Code

ID 1/5 1034 S 2 - Medicare

Coinsurance


CAS06 Monetary Amount R 1/18 782 S Medicare Coinsurance

Amount




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value




Reason Code

ID 1/5 1034 S 3 – Medicare Copay


CAS09 Monetary Amount R 1/18 782 S Medicare Copay

Amount





Reason Code

ID 1/5 1034 S 122 – Medicare

Psychiatric Reduction


CAS12 Monetary Amount R 1/18 782 S Medicare Psychiatric

Reduction Amount



Segment End B 1 ~

2320 AMT Coordination of Benefits

(COB) Allowed Amount

ID 3 S AMT


AMT01 Amount Qualifier Code ID 1/3 522 R D – Payer Paid Amt


AMT02 Monetary Amount R 1/18 782 R Medicare Paid Amount

Segment End B 1 ~

2320 OI Other Insurance

Coverage Information

ID 2 S OI




OI03 Yes/No Condition or

Response Code

ID 1 1073 R Y




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value



OI06 Release of Information

Code

ID 1 1363 R Y

Segment End B 1 ~

2330A NM1 Other Subscriber Name ID 3 S NM1




NM102 Entity Type Qualifier ID 1 1065 R 1 – Person


NM103 Name Last or

Organization Name

AN 1/60 1035 R









Qualifier

ID 1/2 66 R MI


NM109 Identification Code AN 2/80 67 R Medicare Member ID

Segment End B 1 ~

2330B NM1 Other Payer Name ID 3 S NM1






NM103 Name Last or

Organization Name

AN 1/60 1035 R MEDICARE



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value







Qualifier

ID 1/2 66 R MI


NM109 Identification Code AN 2/80 67 R MC01

Segment End B 1 ~

2330B DTP Claim Adjudication Date ID 3 S DTP





Format Qualifier

ID 2/3 1250 R D8


DTP03 Date Time Period AN 1/35 1251 R Medicare Paid Date

CCYYMMDD

Segment End B 1 ~

*** the following

segments are for non-

Medicare COB

information

2320 SBR Other Subscriber

Information

ID 3 S SBR




ID 1 1138 R S


SBR02 Individual Relationship

Code

ID 2 1069 R 18


SBR03 Reference Identification AN 1/50 127 S Insured Group or



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Policy Number


SBR04 Name AN 1/60 93 S OTHERINS







Code

ID 1/2 1032 S ZZ

Segment End B 1 ~

2320 CAS Claim Level

Adjustments

ID 3 S CAS



Group Code

ID 1/2 1033 R PR



Reason Code

ID 1/5 1034 R 1 - Other Insurance

Deductible


CAS03 Monetary Amount R 1/18 782 R Other Insurance

Deductible Amount





Reason Code

ID 1/5 1034 S 2 - Other Insurance

Coinsurance


CAS06 Monetary Amount R 1/18 782 S Other Insurance

Coinsurance Amount






Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value


Reason Code

ID 1/5 1034 S 3 - Other Insurance

Copay



Copay Amount



Segment End B 1 ~

2320 AMT Coordination of Benefits

(COB) Allowed Amount

ID 3 S AMT


AMT01 Amount Qualifier Code ID 1/3 522 R D – Other Insurance

Paid


AMT02 Monetary Amount R 1/18 782 R Other Insurance Paid

Amount

Segment End B 1 ~

2320 OI Other Insurance

Coverage Information

ID 2 S OI




OI03 Yes/No Condition or

Response Code

ID 1 1073 R Y




OI06 Release of Information

Code

ID 1 1363 R Y

Segment End B 1 ~

2330A NM1 Other Subscriber Name ID 3 S NM1





Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value




NM103 Name Last or

Organization Name

AN 1/60 1035 R Other Insurance

Organization Name









Qualifier

ID 1/2 66 R MI


NM109 Identification Code AN 2/80 67 R Other Insurance

Member Id

Segment End B 1 ~

2330B NM1 Other Payer Name ID 3 S NM1






NM103 Name Last or

Organization Name

AN 1/60 1035 R OTHERINS







Qualifier

ID 1/2 66 R PI



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value


NM109 Identification Code AN 2/80 67 R OT01

Segment End B 1 ~

2330B DTP Claim Adjudication Date ID 3 S DTP





Format Qualifier

ID 2/3 1250 R D8


DTP03 Date Time Period AN 1/35 1251 R Other Insurance Paid

Date

CCYYMMDD

Segment End B 1 ~

2400 LX Service Line ID 2 R LX


LX01 Assigned Number N0 1/6 554 R

Segment End B 1 ~

2400 SV2 Institutional Service

Line

ID 3 R SV2


SV201 Product/Service ID AN 1/48 234 R [Revenue Code]


SV202-1 Product/Service ID

Qualifier

ID 2 235 S HC

Component Element

Separator

1 :

SV202-2 Product/Service ID AN 1/48 234 S

Component Element

Separator

1 :

SV202-3 Procedure Modifier AN 2 1339 S

Component Element

Separator

1 :




Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Component Element

Separator

1 :


Component Element

Separator

1 :



SV203 Monetary Amount R 1/18 782 R


SV204 Unit or Basis for

Measurement Code

ID 2 355 R


SV205 Quantity R 1/15 380 R



SV207 Monetary Amount R 1/18 782 S

Segment End B 1 ~

2400 DTP Service Line Date ID 3 S DTP





Format Qualifier

ID 2/3 1250 R D8 or RD8


DTP03 Date Time Period ID 1/35 1251 R CCYYMMDD or

CCYYMMDD-

CCYYMMDD

Segment End B 1 ~

2410 LIN Drug Identification ID 3 S LIN When billing a

prescribed drug

procedure code in

Loop 2400, this Loop

is required.



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value



LIN02 Product/Service ID

Qualifier

ID 2 235 R N4


LIN03 Product/Service ID AN 1/48 234 R National Drug Code

Segment End B 1 ~

2410 CTP Drug Pricing ID 3 S CTP





CTP04 Quantity N 1/15 380 R Drug Unit Count


CTP05-1 Unit or Basis for

Measurement Code

ID 2 355 R Unit of Measurement

Code

Segment End B 1 ~

2420C NM1 Rendering Physician

Name

ID 3 S NM1






NM103 Name Last or

Organization Name

AN 1/60 1035 R










Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value


Qualifier


ID (NPI)



Segment End B 1 ~

2420C REF Rendering Secondary

Identification

ID 3 S REF



Qualifier


Medicaid ID



Segment End B 1 ~

2420D NM1 Referring Physician

Name

ID 3 S NM1


NM101 Entity Identifier Code ID 2/3 98 R ZZ




NM103 Name Last or

Organization Name

AN 1/60 1035 R









Qualifier


ID (NPI)





Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Segment End B 1 ~

2420D REF Referring Provider


ID 3 S REF



Qualifier


Medicaid ID



Segment End B 1 ~

***Medicare

Adjustment Amounts **

2430 SVD Line Adjudication

Information

ID 3 S SVD


SVD01 Identification Code AN 2/80 67 R MC01


SVD02 Monetary Amount R 1/18 782 R Service Line Medicare

Paid Amount


SVD03 Composite Medical

Procedure Identifier

S

SVD03-1 Product/Service ID

Qualifier

ID 2 235 R HC

Component Element

Separator

1 :

SVD03-2 Product/Service ID AN 1/48 234 R Procedure Code

Component Element

Separator

1 :

SVD03-3 Procedure Modifier AN 2 1339 S Modifier

Component Element

Separator

1 :


Component Element

Separator

1 :



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value


Component Element

Separator

1 :


Component Element

Separator

1 :

SVD03-7 Description AN 1/80 352 S


SVD04 Product/Service ID AN 1/48 234 R Revenue Code


SVD05 Quantity R 1/15 380 R Quantity/Units

Segment End B 1 ~

2430 CAS Line Adjustment ID 3 S CAS



Group Code

ID 1/2 1033 R PR



Reason Code

ID 1/5 1034 R 1 – Medicare

Deductible


CAS03 Monetary Amount R 1/18 782 R Medicare Deductible

Amount





Reason Code

ID 1/5 1034 S 2 - Coinsurance


CAS06 Monetary Amount R 1/18 782 S Medicare Coinsurance

Amount




CAS08 Claim Adjustment ID 1/5 1034 S 3 – Medicare Copay



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Reason Code


CAS09 Monetary Amount R 1/18 782 S Medicare Copay

Amount





Reason Code

ID 1/5 1034 S 122 – Medicare

Psychiatric Reduction


CAS12 Monetary Amount R 1/18 782 S Medicare Psychiatric

Reduction



Segment End B 1 ~




Group Code

ID 1/2 1033 R CO



Reason Code

ID 1/5 1034 R Medicare Deductible

Denial Reason

(Action) Code


CAS03 Monetary Amount R 1/18 782 R 0

Segment End B 1 ~

2430 DTP Line Adjudication Date DTP


DTP01 Date/Time Qualifier A/N 3/3 573


DTP02 Date Format Qualifier AN 2/3 D8


DTP03 Payment Date N 35 Medicare Payment



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Date

CCYYMMDD

Segment End B 1 ~

**The following are for

reporting other

insurance payment

information

2430 SVD Line Adjudication

Information

ID 3 S SVD


SVD01 Identification Code AN 2/80 67 R OT01


SVD02 Monetary Amount R 1/18 782 R Service Line Other

Insurance Paid

Amount


SVD03-1 Product/Service ID

Qualifier

ID 2 235 R HC

Component Element

Separator

1 :

SVD03-2 Product/Service ID AN 1/48 234 R Procedure Code

Component Element

Separator

1 :


Component Element

Separator

1 :


Component Element

Separator

1 :


Component Element

Separator

1 :


Component Element 1 :



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Separator

SVD03-7 Description AN 1/80 352 S


SVD04 Product/Service ID AN 1/48 234 R Revenue/Service Code


SVD05 Quantity R 1/15 380 R Quantity/Units

Segment End B 1 ~




Group Code

ID 1/2 1033 R PR



Reason Code

ID 1/5 1034 R 1 – Other Insurance

Deductible


CAS03 Monetary Amount R 1/18 782 R Other Insurance

Deductible Amount





Reason Code

ID 1/5 1034 S 2 - Coinsurance



Coinsurance Amount





Reason Code

ID 1/5 1034 S 3 - Copay



Copay Amount



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value





Reason Code

ID 1/5 1034 S 45– Other Insurance

Allowed



Allowed Amount




Segment End B 1 ~

2430 DTP Line Adjudication Date DTP


DTP01 Date/Time Qualifier A/N 3/3 573


DTP02 Date Format Qualifier AN 2/3 D8


DTP03 Payment Date N 35 Other Insurance

Payment Date

CCYYMMDD

Segment End B 1 ~

TRAILER SE Transaction Set Trailer ID 2 R SE


SE01 Number of Included

Segments

N0 1/10 96 R


SE02 Transaction Set Control

Number

AN 4/9 329 R

Segment End B 1 ~

GE Functional Group Trailer ID 2 R GE


GE01 Number of Transaction N0 1/6 97 R



Loop Segment

ID

Segment Name/ Data

Element Name


#

Req Des. Value

Sets Included


GE02 Group Control Number N0 1/9 28 R

Segment End B 1 ~

IEA Interchange Control

Number

ID 3 R IEA


IEA01 Number of Included

Functional Groups

N0 1/5 I16 R


IEA02 Interchange Control

Number

N0 9 I12 R Must be identical to

the value in ISA13

Segment End B 1 ~



Appendix A.

Please see Appendix_A_Vendor_Specs-5010.docx.

Documents

Vendor Specifications 837 Institutional Claim ASC X12N ... Companion Guides... · Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010 Last Updated: 09/19/2019 Page 1 of