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
5.0 9/24/2014 TQD DHW validated 9/23/14
5.1 5/21/2015 M McFadden Semi-annual review performed – made changes
6.0 6/8/2015 TQD DHW validated 6/5/15
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
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
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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
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.
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
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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.
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 3 of 47
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
Element Separator AN 1 *
ISA02 Authorization
Information
AN 10 I02 R Space fill
Element Separator AN 1 *
ISA03 Security Information
Qualifier
ID 2 I03 R 00
Element Separator AN 1 *
ISA04 Security Information AN 10 I04 R Space fill
Element Separator AN 1 *
ISA05 Interchange ID Qualifier ID 2 I05 R ZZ
Element Separator AN 1 *
ISA06 Interchange Sender ID AN 15 I06 R Molina assigned
trading partner ID + 3
spaces. i.e.
IDTPID000001 + 3
spaces
Element Separator AN 1 *
ISA07 Interchange ID Qualifier ID 2 I05 R ZZ
Element Separator AN 1 *
ISA08 Interchange Receiver ID AN 15 I07 R ID_MMIS_4MOLINA
Element Separator AN 1 *
ISA09 Interchange Date DT 6 I08 R YYMMDD
Element Separator AN 1 *
ISA10 Interchange Time TM 4 I09 R HHMM
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
ISA11 Interchange Control ID ID 1 I10 R ^
Element Separator AN 1 *
ISA12 Interchange Version
Number
ID 5 I11 R 00501
Element Separator AN 1 *
ISA13 Interchange Control
Number
N0 9 I12 R Must be identical to
the interchange trailer
IEA02 (defined by
sending Trading
Partner)
Element Separator AN 1 *
ISA14 Ack. Requested ID 1 I13 R 1 (Interchange
acknowledgement
requested)
Element Separator AN 1 *
ISA15 Usage Indicator ID 1 I14 R P or T (Must contain a
“P” indicator in
production)
Element Separator AN 1 *
ISA16 Component Element
Separator
1 I15 R :
Segment End B 1 ~
GS Functional Group
Header
2 R GS
Element Separator AN 1 *
GS01 Functional Identifier
Code
ID 2 479 R HC
Element Separator AN 1 *
GS02 Application Sender's
Code
AN 2/15 142 R Molina assigned
trading partner ID
Element Separator AN 1 *
GS03 Application Receiver's
Code
AN 15 124 R ID_MMIS_4MOLINA
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
GS04 Date DT 8 373 R CCYYMMDD
Element Separator AN 1 *
GS05 Time TM 4/8 337 R HHMM
Element Separator AN 1 *
GS06 Group Control Number N0 1/9 28 R Assigned by Sender
Element Separator AN 1 *
GS07 Responsible Agency
Code
ID 1/2 455 R X
Element Separator AN 1 *
GS08 Version / Release Code AN 12 480 R 005010X223A2
Segment End B 1 ~
ST Transaction Set Header 2 R ST
Element Separator AN 1 *
ST01 Transaction Set
Identifier Code
ID 3 143 R 837
Element Separator AN 1 *
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
Element Separator AN 1 *
BHT01 Hierarchical Structure
Code
ID 4 1005 R 0019
Element Separator AN 1 *
BHT02 Transaction Set Purpose
Code
ID 2 353 R ‘00’ Original
Element Separator AN 1 *
BHT03 Reference identification AN 1/30 127 R Submitter Transaction
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Identifier
Element Separator AN 1 *
BHT04 Date DT 8 373 R CCYYMMDD
Element Separator AN 1 *
BHT05 Time TM 4/8 337 R HHMM
Element Separator AN 1 *
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
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R 41
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1 or 2
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S
Element Separator AN 1 *
NM105 Name Middle AN 1 1037 S
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R 46
Element Separator AN 1 *
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
Element Separator AN 1 *
PER01 Contact Function Code ID 2/2 366 R IC
Element Separator AN 1 *
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
PER02 Name AN 1/60 93 R
Element Separator AN 1 *
PER03 Communication Number
Qualifier
ID 2/2 365 R TE = Telephone
Element Separator AN 1 *
PER04 Communication Number AN 1/256 364 R
Segment End B 1 ~
1000B NM1 Receiver Name ID 3 R NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R 40
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 2
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 60 1035 R ID_MMIS_4MOLINA
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R 46
Element Separator AN 1 *
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
Element Separator AN 1 *
HL01 Hierarchical ID Number AN 1 628 R 1
Element Separator AN 1 *
Element Separator AN 1 *
HL03 Hierarchical Level Code ID 1/2 735 R 20
Element Separator AN 1 *
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
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
PRV01 Provider Code ID 1/3 1221 R BI = Billing
Element Separator AN 1 *
PRV02 Reference Identification
Qualifier
ID 2/3 128 R PXC
Element Separator AN 1 *
PRV03 Reference Identification AN 1/50 127 R Provider Taxonomy
Code
Segment End B 1 ~
2010AA NM1 Billing Provider Name ID 3 R NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R 85
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 2
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 S XX = National
Provider ID (NPI)
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 S NPI
Segment End B 1 ~
2010AA N3 Billing Provider Address ID 2 R N3
Element Separator AN 1 *
N301 Address Information AN 1/55 166 R
Element Separator AN 1 *
N302 Address Information AN 1/55 166 S Required if a second
address line exists.
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Segment End B 1 ~
2010AA N4 Billing Provider
City/State/Zip Code
ID 2 R N4
Element Separator AN 1 *
N401 City Name AN 2/30 19 R
Element Separator AN 1 *
N402 State or Province Code ID 2 156 R
Element Separator AN 1 *
N403 Postal Code ID 5/15 116 R
Segment End B 1 ~
2010AA REF Billing Provider
Secondary Identification
Number
ID 3 R
Element Separator AN 1 *
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
Element Separator AN 1 *
HL01 Hierarchical ID Number AN 1 628 R 2
Element Separator AN 1 *
HL02 Hierarchical Parent ID
Number
AN 1/12 734 R
Element Separator AN 1 *
HL03 Hierarchical Level Code ID 1/2 735 R 22
Element Separator AN 1 *
HL04 Hierarchical Child Code ID 1 736 R 0
Segment End B 1 ~
2000B SBR Subscriber Information ID 3 R SBR
Element Separator AN 1 *
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
SBR01 Payer Responsibility
Sequence Number Code
ID 1 1138 R P, S or T
Element Separator AN 1 *
SBR02 Individual Relationship
Code
ID 2 1069 S 18
Element Separator AN 1 *
SBR03 Reference Identification AN 1/50 127 S
Element Separator AN 1 *
SBR04 Name AN 1/60 93 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
SBR09 Claim Filing Indicator
Code
ID 1/2 1032 S MC = Medicaid
Segment End B 1 ~
2010BA NM1 Subscriber Name ID 3 R NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R IL
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1 = Person
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S
Element Separator AN 1 *
Element Separator AN 1 *
NM107 Name Suffix AN 1/10 1039 S
Element Separator AN 1 *
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
NM108 Identification Code
Qualifier
ID 1/2 66 R MI = Member
Identification Number
Element Separator AN 1 *
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
Element Separator AN 1 *
N301 Address Information AN 1/55 166 R
Element Separator AN 1 *
N302 Address Information AN 1/55 166 S
Segment End B 1 ~
2010BA N4 Subscriber
City/State/Zip Code
ID 2 R N4
Element Separator AN 1 *
N401 City Name AN 2/30 19 R
Element Separator AN 1 *
N402 State or Province Code ID 2 156 R
Element Separator AN 1 *
N403 Postal Code ID 5/15 116 R
Segment End B 1 ~
2010BA DMG Demographic
Information
ID 3 DMG
Element Separator AN 1 *
DMG01 Date Time Period
Format Qualifier
ID 2/3 1250 D8
Element Separator AN 1 *
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
DMG02 Date Time Period AN 1/35 1251 Date of birth
CCYYMMDD
Element Separator AN 1 *
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
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R PR
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 2
Element Separator AN 1 *
NM103 Name Last or
Organization
AN 1/60 1035 R ID_MMIS_4MOLINA
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R PI = Payer
Identification
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R ID_MMIS_4MOLINA
Segment End B 1 ~
REF Billing Provider
Secondary Identification
ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 R G2
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 R Provider Medicaid ID
(Atypical Providers)
Segment End B 1 ~
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
2300 CLM Claim Information ID 3 R CLM
Element Separator AN 1 *
CLM01 Claim Submitter’s
Identifier
AN (1/20) 1028 R
Element Separator AN 1 *
CLM02 Monetary Amount R 1/18 782 R
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
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
Element Separator AN 1 *
Element Separator AN 1 *
CLM07 Provider Accept
Assignment Code
ID 1/1 1359 O
Element Separator AN 1 *
CLM08 Yes/No Condition or
Response Code
ID 1 1073 R Y
Element Separator AN 1 *
CLM09 Release of Information
Code
ID 1 1363 R Y
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
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
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 096
Element Separator AN 1 *
DTP02 Date Time Period
Format Qualifier
ID 2/3 1250 R TM
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R HHMM
Segment End B 1 ~
2300 DTP Statement Dates ID 3 R DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 434
Element Separator AN 1 *
DTP02 Date Time Period
Format Qualifier
ID 2/3 1250 R RD8
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R CCYYMMDD-
CCYYMMDD
Segment End B 1 ~
2300 DTP Admission Date/Hour ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 435
Element Separator AN 1 *
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
DTP02 Date Time Period
Format Qualifier
ID 2/3 1250 R DT
Element Separator AN 1 *
DTP03 Date Time Period AN 1/35 1251 R CCYYMMDDHHMM
Segment End B 1 ~
2300 CL1 Institutional Claim Code ID 3 R CL1
Element Separator AN 1 *
CL101 Priority (Type) of
Admission or Visit
ID 1 1315 R
Element Separator AN 1 *
CL102 Point of Origin for
Admission or Visit
ID 1 1314 S
Element Separator AN 1 *
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
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R 9F = Referral
Element Separator AN 1 *
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 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R G1 = Prior
Authorization Number
Element Separator AN 1 *
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
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
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R F8 = Original
Reference Number
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R
Segment End B 1 ~
2300 REF Medical Record Number ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R EA
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R
Segment End B 1 ~
2300 HI Principal Diagnosis
Information
ID 2 S HI
Element Separator AN 1 *
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
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Indicator
Segment End B 1 ~
2300 HI Admitting Diagnosis
Information
ID 2 S HI
Element Separator AN 1 *
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
Separators (for ‘not
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
Element Separator AN 1 *
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
Separators (for ‘not
AN 1 :::::::
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
used’ elements)
HI01-9 Present on Admission
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
Element Separator AN 1 *
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
Separators (for ‘not
used’ elements)
AN 1 :::::::
HI01-9 Present on Admission
Indicator
ID 1 1073
Note: Can be up to 12
HI0x-1 thru HI0x-9
elements separated
by *
Segment End B 1 ~
2300 HI Other Diagnosis
Information
ID 2 S HI
Element Separator AN 1 *
HI01-1 Code List Qualifier Code ID 1/3 1270 R BF (ICD-9) – Other
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 19 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
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
Separators (for ‘not
used’ elements)
AN 1 :::::::
HI01-9 Present on Admission
Indicator
ID 1 1073
Note: Can be up to 12
HI0x-1 thru HI0x-9
elements separated
by *
Segment End B 1 ~
2300 HI Principal Procedure
Information
ID 2 S HI
Element Separator AN 1 *
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
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
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Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Segment End B 1 ~
2300 HI Other Procedure
Information
ID 2 S HI
Element Separator AN 1 *
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 :
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
Element Separator AN 1 *
Note: Can be up to 12
HI0x-1 through HI0x-
4 elements separated
by *
Segment End B 1 ~
2300 HI Occurrence Span
Information
ID 2 S HI
Element Separator AN 1 *
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
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 21 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Format Qualifier
Component Element
Separator
1 :
HI01-4 Date Time Period AN 1/35 1251 S CCYYMMDD-
CCYYMMDD
Note: Can be up to 12
HI0x-1 through HI0x-
4 elements separated
by *
Segment End B 1 ~
2300 HI Occurrence Information ID 2 S HI
Element Separator AN 1 *
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 :
HI01-3 Date Time Period
Format Qualifier
ID 2/3 1250 R D8
Component Element
Separator
1 :
HI01-4 Date Time Period AN 1/35 1251 R CCYYMMDD
Note: Can be up to 12
HI0x-1 through HI0x-
4 elements separated
by *
Segment End B 1 ~
2300 HI Value Information
Codes
ID 2 S HI
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 22 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
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
Note: Can be up to 12
HI0x-1 through HI0x-
2 elements separated
by *
Segment End B 1 ~
2300 HI Condition Information ID 2 S HI
Element Separator AN 1 *
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
Note: Can be up to 12
HI0x-1 through HI0x-
2 elements separated
by *
Segment End B 1 ~
2310A NM1 Attending Physician
Name
ID 3 S NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R 71
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1 – Person
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S
Element Separator AN 1 *
Element Separator AN 1 *
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 23 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 S XX = National
Provider ID (NPI)
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 S NPI
Segment End B 1 ~
2310A PRV Attending Physician
Specialty Information
ID 3 S PRV
Element Separator AN 1 *
PRV01 Provider Code ID 1/3 1221 R AT
Element Separator AN 1 *
PRV02 Reference Identification
Qualifier
ID 2/3 128 R PXC
Element Separator AN 1 *
PRV03 Reference Identification AN 1/50 127 R Provider Taxonomy
Code
Segment End B 1 ~
2310A REF Attending Physician
Secondary Identification
ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R EI = Employer’s
Identification Number
G2= Provider
Medicaid ID
Element Separator AN 1 *
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
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R 72
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 24 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1 - person
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 R
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
NM108 Identification Code
Qualifier
AN 2 XX = National
Provider ID (NPI)
Element Separator AN 1 *
NM109 Identification Code AN 2/80 R NPI
Segment End B 1 ~
2310B REF Operating Physician
Secondary Identification
ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 R G2 = Provider
Medicaid ID
Element Separator AN 1 *
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
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R ZZ
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1 – person
Element Separator AN 1 *
NM103 Name Last or AN 1/60 1035 R
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 25 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Organization Name
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R XX=National Provider
ID (NPI)
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R NPI
Segment End B 1 ~
2310C REF Other Provider
Secondary Identification
ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R EI = EIN
G2 = Provider
Medicaid ID
Element Separator AN 1 *
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
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R 82
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1 – person
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 26 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R XX=National Provider
ID (NPI)
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R NPI
Segment End B 1 ~
2310D REF Rendering Secondary
Identification
ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R G2 = Provider
Medicaid ID
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R Provider Medicaid ID
Segment End B 1 ~
2310E NM1 Service Facility Name ID 3 S NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R 77
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 2
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R Service Location
Name
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
NM108 Identification Code
Qualifier
AN ½ 66 S XX=National Provider
ID (NPI)
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 27 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
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
N301 Address Information AN 1/55 166 R
Element Separator AN 1 *
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
Element Separator AN 1 *
N402 State ID 2 156 R
Element Separator AN 1 *
N403 Zip Code AN 3/15 116 R
Segment End B 1 ~
2310E REF Service Facility
Secondary Identification
ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R LU
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R Service Location
Identifier
Segment End B 1 ~
2310F NM1 Referring Physician
Name
ID 3 S NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R DN
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1 – person
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 28 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R XX=National Provider
ID (NPI)
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R NPI
Segment End B 1 ~
2310F REF Referring Provider
Secondary Identification
ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R G2 = Provider
Medicaid ID
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R Provider Medicaid ID
Segment End B 1 ~
** for Medicare COB
information the
following segments are
required **
2320 SBR Other Subscriber
Information
ID 3 S SBR
Element Separator AN 1 *
SBR01 Payer Responsibility
Sequence Number Code
ID 1 1138 R P
Element Separator AN 1 *
SBR02 Individual Relationship ID 2 1069 R 18
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 29 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Code
Element Separator AN 1 *
SBR03 Reference Identification AN 1/50 127 S Insured Group or
Policy Number
Element Separator AN 1 *
SBR04 Name AN 1/60 93 S MEDICARE
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
SBR09 Claim Filing Indicator
Code
ID 1/2 1032 S MA
Segment End B 1 ~
2320 CAS Claim Level
Adjustments
ID 3 S CAS
Element Separator AN 1 *
CAS01 Claim Adjustment
Group Code
ID 1/2 1033 R PR
Element Separator AN 1 *
CAS02 Claim Adjustment
Reason Code
ID 1/5 1034 R 1 - for Medicare
Deductible
Element Separator AN 1 *
CAS03 Monetary Amount R 1/18 782 R Medicare Deductible
Amount
Element Separator AN 1 *
CAS04 Quantity R 1/15 380 S
Element Separator AN 1 *
CAS05 Claim Adjustment
Reason Code
ID 1/5 1034 S 2 - Medicare
Coinsurance
Element Separator AN 1 *
CAS06 Monetary Amount R 1/18 782 S Medicare Coinsurance
Amount
Element Separator AN 1 *
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 30 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
CAS07 Quantity R 1/15 380 S
Element Separator AN 1 *
CAS08 Claim Adjustment
Reason Code
ID 1/5 1034 S 3 – Medicare Copay
Element Separator AN 1 *
CAS09 Monetary Amount R 1/18 782 S Medicare Copay
Amount
Element Separator AN 1 *
CAS10 Quantity R 1/15 380 S
Element Separator AN 1 *
CAS11 Claim Adjustment
Reason Code
ID 1/5 1034 S 122 – Medicare
Psychiatric Reduction
Element Separator AN 1 *
CAS12 Monetary Amount R 1/18 782 S Medicare Psychiatric
Reduction Amount
Element Separator AN 1 *
CAS13 Quantity R 1/15 380 S
Segment End B 1 ~
2320 AMT Coordination of Benefits
(COB) Allowed Amount
ID 3 S AMT
Element Separator AN 1 *
AMT01 Amount Qualifier Code ID 1/3 522 R D – Payer Paid Amt
Element Separator AN 1 *
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
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
OI03 Yes/No Condition or
Response Code
ID 1 1073 R Y
Element Separator AN 1 *
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 31 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
Element Separator AN 1 *
OI06 Release of Information
Code
ID 1 1363 R Y
Segment End B 1 ~
2330A NM1 Other Subscriber Name ID 3 S NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R IL
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1 – Person
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R MI
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R Medicare Member ID
Segment End B 1 ~
2330B NM1 Other Payer Name ID 3 S NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R PR
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 2
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R MEDICARE
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 32 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R MI
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R MC01
Segment End B 1 ~
2330B DTP Claim Adjudication Date ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 573
Element Separator AN 1 *
DTP02 Date Time Period
Format Qualifier
ID 2/3 1250 R D8
Element Separator AN 1 *
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
Element Separator AN 1 *
SBR01 Payer Responsibility
Sequence Number Code
ID 1 1138 R S
Element Separator AN 1 *
SBR02 Individual Relationship
Code
ID 2 1069 R 18
Element Separator AN 1 *
SBR03 Reference Identification AN 1/50 127 S Insured Group or
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 33 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Policy Number
Element Separator AN 1 *
SBR04 Name AN 1/60 93 S OTHERINS
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
SBR09 Claim Filing Indicator
Code
ID 1/2 1032 S ZZ
Segment End B 1 ~
2320 CAS Claim Level
Adjustments
ID 3 S CAS
Element Separator AN 1 *
CAS01 Claim Adjustment
Group Code
ID 1/2 1033 R PR
Element Separator AN 1 *
CAS02 Claim Adjustment
Reason Code
ID 1/5 1034 R 1 - Other Insurance
Deductible
Element Separator AN 1 *
CAS03 Monetary Amount R 1/18 782 R Other Insurance
Deductible Amount
Element Separator AN 1 *
CAS04 Quantity R 1/15 380 S
Element Separator AN 1 *
CAS05 Claim Adjustment
Reason Code
ID 1/5 1034 S 2 - Other Insurance
Coinsurance
Element Separator AN 1 *
CAS06 Monetary Amount R 1/18 782 S Other Insurance
Coinsurance Amount
Element Separator AN 1 *
CAS07 Quantity R 1/15 380 S
Element Separator AN 1 *
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 34 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
CAS08 Claim Adjustment
Reason Code
ID 1/5 1034 S 3 - Other Insurance
Copay
Element Separator AN 1 *
CAS09 Monetary Amount R 1/18 782 S Other Insurance
Copay Amount
Element Separator AN 1 *
CAS10 Quantity R 1/15 380 S
Segment End B 1 ~
2320 AMT Coordination of Benefits
(COB) Allowed Amount
ID 3 S AMT
Element Separator AN 1 *
AMT01 Amount Qualifier Code ID 1/3 522 R D – Other Insurance
Paid
Element Separator AN 1 *
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
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
OI03 Yes/No Condition or
Response Code
ID 1 1073 R Y
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
OI06 Release of Information
Code
ID 1 1363 R Y
Segment End B 1 ~
2330A NM1 Other Subscriber Name ID 3 S NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R IL
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 35 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R Other Insurance
Organization Name
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R MI
Element Separator AN 1 *
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
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R PR
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 2
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R OTHERINS
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R PI
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 36 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R OT01
Segment End B 1 ~
2330B DTP Claim Adjudication Date ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 573
Element Separator AN 1 *
DTP02 Date Time Period
Format Qualifier
ID 2/3 1250 R D8
Element Separator AN 1 *
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
Element Separator AN 1 *
LX01 Assigned Number N0 1/6 554 R
Segment End B 1 ~
2400 SV2 Institutional Service
Line
ID 3 R SV2
Element Separator AN 1 *
SV201 Product/Service ID AN 1/48 234 R [Revenue Code]
Element Separator AN 1 *
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 :
SV202-4 Procedure Modifier AN 2 1339 S
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 37 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Component Element
Separator
1 :
SV202-5 Procedure Modifier AN 2 1339 S
Component Element
Separator
1 :
SV202-6 Procedure Modifier AN 2 1339 S
Element Separator AN 1 *
SV203 Monetary Amount R 1/18 782 R
Element Separator AN 1 *
SV204 Unit or Basis for
Measurement Code
ID 2 355 R
Element Separator AN 1 *
SV205 Quantity R 1/15 380 R
Element Separator AN 1 *
Element Separator AN 1 *
SV207 Monetary Amount R 1/18 782 S
Segment End B 1 ~
2400 DTP Service Line Date ID 3 S DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier ID 3 374 R 472
Element Separator AN 1 *
DTP02 Date Time Period
Format Qualifier
ID 2/3 1250 R D8 or RD8
Element Separator AN 1 *
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.
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 38 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
Element Separator AN 1 *
LIN02 Product/Service ID
Qualifier
ID 2 235 R N4
Element Separator AN 1 *
LIN03 Product/Service ID AN 1/48 234 R National Drug Code
Segment End B 1 ~
2410 CTP Drug Pricing ID 3 S CTP
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
CTP04 Quantity N 1/15 380 R Drug Unit Count
Element Separator AN 1 *
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
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R 82
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1 – person
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 39 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
NM108 Identification Code
Qualifier
ID 1/2 66 R XX=National Provider
ID (NPI)
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R NPI
Segment End B 1 ~
2420C REF Rendering Secondary
Identification
ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R G2 = Provider
Medicaid ID
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R Provider Medicaid ID
Segment End B 1 ~
2420D NM1 Referring Physician
Name
ID 3 S NM1
Element Separator AN 1 *
NM101 Entity Identifier Code ID 2/3 98 R ZZ
Element Separator AN 1 *
NM102 Entity Type Qualifier ID 1 1065 R 1 – person
Element Separator AN 1 *
NM103 Name Last or
Organization Name
AN 1/60 1035 R
Element Separator AN 1 *
NM104 Name First AN 1/35 1036 S
Element Separator AN 1 *
NM105 Name Middle AN 1/25 1037 S
Element Separator AN 1 *
Element Separator AN 1 *
Element Separator AN 1 *
NM108 Identification Code
Qualifier
ID 1/2 66 R XX=National Provider
ID (NPI)
Element Separator AN 1 *
NM109 Identification Code AN 2/80 67 R NPI
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 40 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Segment End B 1 ~
2420D REF Referring Provider
Secondary Identification
ID 3 S REF
Element Separator AN 1 *
REF01 Reference Identification
Qualifier
ID 2/3 128 R G2 = Provider
Medicaid ID
Element Separator AN 1 *
REF02 Reference Identification AN 1/50 127 R Provider Medicaid ID
Segment End B 1 ~
***Medicare
Adjustment Amounts **
2430 SVD Line Adjudication
Information
ID 3 S SVD
Element Separator AN 1 *
SVD01 Identification Code AN 2/80 67 R MC01
Element Separator AN 1 *
SVD02 Monetary Amount R 1/18 782 R Service Line Medicare
Paid Amount
Element Separator AN 1 *
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 :
SVD03-4 Procedure Modifier AN 2 1339 S Modifier
Component Element
Separator
1 :
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 41 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
SVD03-5 Procedure Modifier AN 2 1339 S Modifier
Component Element
Separator
1 :
SVD03-6 Procedure Modifier AN 2 1339 S Modifier
Component Element
Separator
1 :
SVD03-7 Description AN 1/80 352 S
Element Separator AN 1 *
SVD04 Product/Service ID AN 1/48 234 R Revenue Code
Element Separator AN 1 *
SVD05 Quantity R 1/15 380 R Quantity/Units
Segment End B 1 ~
2430 CAS Line Adjustment ID 3 S CAS
Element Separator AN 1 *
CAS01 Claim Adjustment
Group Code
ID 1/2 1033 R PR
Element Separator AN 1 *
CAS02 Claim Adjustment
Reason Code
ID 1/5 1034 R 1 – Medicare
Deductible
Element Separator AN 1 *
CAS03 Monetary Amount R 1/18 782 R Medicare Deductible
Amount
Element Separator AN 1 *
CAS04 Quantity R 1/15 380 S
Element Separator AN 1 *
CAS05 Claim Adjustment
Reason Code
ID 1/5 1034 S 2 - Coinsurance
Element Separator AN 1 *
CAS06 Monetary Amount R 1/18 782 S Medicare Coinsurance
Amount
Element Separator AN 1 *
CAS07 Quantity R 1/15 380 S
Element Separator AN 1 *
CAS08 Claim Adjustment ID 1/5 1034 S 3 – Medicare Copay
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 42 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Reason Code
Element Separator AN 1 *
CAS09 Monetary Amount R 1/18 782 S Medicare Copay
Amount
Element Separator AN 1 *
CAS10 Quantity R 1/15 380 S
Element Separator AN 1 *
CAS11 Claim Adjustment
Reason Code
ID 1/5 1034 S 122 – Medicare
Psychiatric Reduction
Element Separator AN 1 *
CAS12 Monetary Amount R 1/18 782 S Medicare Psychiatric
Reduction
Element Separator AN 1 *
CAS13 Quantity R 1/15 380 S
Segment End B 1 ~
2430 CAS Line Adjustment ID 3 S CAS
Element Separator AN 1 *
CAS01 Claim Adjustment
Group Code
ID 1/2 1033 R CO
Element Separator AN 1 *
CAS02 Claim Adjustment
Reason Code
ID 1/5 1034 R Medicare Deductible
Denial Reason
(Action) Code
Element Separator AN 1 *
CAS03 Monetary Amount R 1/18 782 R 0
Segment End B 1 ~
2430 DTP Line Adjudication Date DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier A/N 3/3 573
Element Separator AN 1 *
DTP02 Date Format Qualifier AN 2/3 D8
Element Separator AN 1 *
DTP03 Payment Date N 35 Medicare Payment
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 43 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
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
Element Separator AN 1 *
SVD01 Identification Code AN 2/80 67 R OT01
Element Separator AN 1 *
SVD02 Monetary Amount R 1/18 782 R Service Line Other
Insurance Paid
Amount
Element Separator AN 1 *
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 :
SVD03-4 Procedure Modifier AN 2 1339 S Modifier
Component Element
Separator
1 :
SVD03-5 Procedure Modifier AN 2 1339 S Modifier
Component Element
Separator
1 :
SVD03-6 Procedure Modifier AN 2 1339 S Modifier
Component Element 1 :
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 44 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Separator
SVD03-7 Description AN 1/80 352 S
Element Separator AN 1 *
SVD04 Product/Service ID AN 1/48 234 R Revenue/Service Code
Element Separator AN 1 *
SVD05 Quantity R 1/15 380 R Quantity/Units
Segment End B 1 ~
2430 CAS Line Adjustment ID 3 S CAS
Element Separator AN 1 *
CAS01 Claim Adjustment
Group Code
ID 1/2 1033 R PR
Element Separator AN 1 *
CAS02 Claim Adjustment
Reason Code
ID 1/5 1034 R 1 – Other Insurance
Deductible
Element Separator AN 1 *
CAS03 Monetary Amount R 1/18 782 R Other Insurance
Deductible Amount
Element Separator AN 1 *
CAS04 Quantity R 1/15 380 S
Element Separator AN 1 *
CAS05 Claim Adjustment
Reason Code
ID 1/5 1034 S 2 - Coinsurance
Element Separator AN 1 *
CAS06 Monetary Amount R 1/18 782 S Other Insurance
Coinsurance Amount
Element Separator AN 1 *
CAS07 Quantity R 1/15 380 S
Element Separator AN 1 *
CAS08 Claim Adjustment
Reason Code
ID 1/5 1034 S 3 - Copay
Element Separator AN 1 *
CAS09 Monetary Amount R 1/18 782 S Other Insurance
Copay Amount
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 45 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Element Separator AN 1 *
CAS10 Quantity R 1/15 380 S
Element Separator AN 1 *
CAS11 Claim Adjustment
Reason Code
ID 1/5 1034 S 45– Other Insurance
Allowed
Element Separator AN 1 *
CAS12 Monetary Amount R 1/18 782 S Other Insurance
Allowed Amount
Element Separator AN 1 *
CAS13 Quantity R 1/15 380 S
Element Separator AN 1 *
Segment End B 1 ~
2430 DTP Line Adjudication Date DTP
Element Separator AN 1 *
DTP01 Date/Time Qualifier A/N 3/3 573
Element Separator AN 1 *
DTP02 Date Format Qualifier AN 2/3 D8
Element Separator AN 1 *
DTP03 Payment Date N 35 Other Insurance
Payment Date
CCYYMMDD
Segment End B 1 ~
TRAILER SE Transaction Set Trailer ID 2 R SE
Element Separator AN 1 *
SE01 Number of Included
Segments
N0 1/10 96 R
Element Separator AN 1 *
SE02 Transaction Set Control
Number
AN 4/9 329 R
Segment End B 1 ~
GE Functional Group Trailer ID 2 R GE
Element Separator AN 1 *
GE01 Number of Transaction N0 1/6 97 R
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 46 of 47
Loop Segment
ID
Segment Name/ Data
Element Name
Format Length DE Ref
#
Req Des. Value
Sets Included
Element Separator AN 1 *
GE02 Group Control Number N0 1/9 28 R
Segment End B 1 ~
IEA Interchange Control
Number
ID 3 R IEA
Element Separator AN 1 *
IEA01 Number of Included
Functional Groups
N0 1/5 I16 R
Element Separator AN 1 *
IEA02 Interchange Control
Number
N0 9 I12 R Must be identical to
the value in ISA13
Segment End B 1 ~
Idaho MMIS Vendor Specifications - 837 Institutional Claim-5010
Last Updated: 09/19/2019 Page 47 of 47
Appendix A.
Please see Appendix_A_Vendor_Specs-5010.docx.