Intellect™
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Electronic Claim Resources
837 Health Care Claim Institutional Review
Due to the width of this grid, this may need to be viewed as a full screen (close side frame ) or use the scroll bar.
This review was prepared based on Medi-Cal's Institutional Outpatient Companion Guide. There may be variances from carrier to carrier and claim to claim.
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LOOP |
POSITION |
SEGMENT ID |
X-12 |
SEGMENT NAME |
NOTES |
Located in Intellect Software |
ISA |
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ISA |
R |
Interchange Control Header |
Starts and identifies an interchange of zero or more functional groups and interchange-related control segments. |
Automatically entered by Intellect |
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GS |
R |
Functional Group Header |
Indicates the beginning of a functional group and provides control information |
Automatically entered by Intellect |
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5 |
ST |
R |
Transaction Set Header |
Start transaction set and assign a control number |
Automatically entered by Intellect |
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10 |
BHT |
R |
Beginning Hierarchy Transaction |
Indicates beginning of a transaction set |
Automatically entered by Intellect |
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BHT01 |
R |
Hierarchical Structure Code |
Indicates the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set |
Automatically entered by Intellect |
0019 - Information Source, Subscriber, Dependent |
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BHT02 |
R |
Transaction Set Purpose Code |
Identify purpose of the 837 transaction set |
Automatically entered by Intellect |
00 - Original: transmission which have never been sent to the receiver |
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18 - Reissue: resending transmission that have been previously sent |
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BHT03 |
R |
Reference Identification |
Number assigned by the originator to identify the transaction within the originator's business application system. |
Automatically entered by Intellect |
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BHT04 |
R |
Date |
Date of transaction creation |
Automatically entered by Intellect |
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BHT05 |
R |
Time |
Time of transaction creation |
Automatically entered by Intellect |
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BHT06 |
R |
Transaction Type Code |
Specifies the type of transaction: claims or encounters |
Automatically entered by Intellect |
CH - Chargeable: when transmission contains claims only |
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RP - Reporting: when transmission contains encounters only |
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15 |
REF |
R |
Transmission Type Identification |
Specifies identifying information |
Automatically entered by Intellect |
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REF01 |
R |
Reference Identification Qualifier |
Code qualifying the Reference Identification |
Automatically entered by Intellect |
87 - Functional Category |
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REF02 |
R |
Reference Identification |
Reference information as defined for a particular Transaction Set or as specified by the Reference ID Qualifier: |
Automatically entered by Intellect |
004010X098A1 for production Professional Claims |
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1000A |
20 |
NM1 |
R |
Submitter Name |
To supply the full name of an individual or organizational entity |
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NM101 |
R |
Entity Identifier Code |
Code identifying an organizational entity, a physical location, property or an individual |
Automatically entered by Intellect |
41 - Submitter |
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NM102 |
R |
Entity Type Qualifier |
Code qualifying the type of entity (NM102 qualifies NM103) |
Automatically entered by Intellect |
1 - Person |
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2 - Non-Person Entity |
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NM103 |
R |
Name Last or Organization Name |
Submitter's last name or organizational name |
Utility --►Set Up --► Clinic <Name> |
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NM108 |
R |
Identification Code Qualifier |
Code designating the system/method of code structure used for the identification code |
Automatically entered by Intellect |
46 - Electronic Transmitter ID Number (ETIN); established by a trading partner agreement |
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45 |
PER |
R |
Submitter EDI Contact Information |
Contact person from submitter organization. |
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PER01 |
R |
Contact Function Code |
Code identifying the major duty or responsibility of the person or group named |
Automatically entered by Intellect |
IC - Information Contact |
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PER02 |
R |
Name |
Free-form name of contact |
Utility --►Set Up --►Security --► Login Users <Operator Name> |
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PER03 |
R |
Communication Number Qualifier |
Code identifying the type of communication number |
Telephone Automatically entered by Intellect |
ED - EDI Access Number |
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EM - E-mail address |
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FX - Fax Number |
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TE - Telephone Number |
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PER04 |
R |
Communication Number |
Complete communications number including area code |
Utility --►Set Up --► Clinic <Phone> |
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1000B |
20 |
NM1 |
R |
Receiver Name |
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NM101 |
R |
Entity Identifier Code |
Code identifying an organizational entity, a physical location, property or an individual |
Automatically entered by Intellect |
40 - Receiver |
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NM102 |
R |
Entity Type Qualifier |
Code qualifying the type of entity (NM102 qualifies NM103) |
Automatically entered by Intellect |
1 - Person |
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2 - Non-Person Entity |
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NM103 |
R |
Name Last or Organization Name |
Receiver's last name or organizational name |
Utility --► Insurance <Name> for the Billing --► Tele Com --► Submit <Insurance Code> |
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NM108 |
R |
Identification Code Qualifier |
Code designating the system/method of code structure used for the identification code 46 - Electronic Transmitter ID Number (ETIN); established by a trading partner agreement |
Automatically entered by Intellect |
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NM109 |
R |
Identification Code |
Code identifying a party or other code |
Utility --► Insurance <Receiver Code> |
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2000A |
1 |
HL |
R |
Billing/Pay-To Provider Hierarchical Level |
To identify dependencies among and the content of hierarchically related groups of data segments |
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HL01 |
R |
Hierarchical ID Number |
HL01 must begin with '1' and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01. |
Automatically entered by Intellect |
1 - 1st HL segment |
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HL03 |
R |
Hierarchical Level Code |
Code defining the characteristic of a level in a hierarchical structure |
Automatically entered by Intellect |
20 - Information Source |
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HL04 |
R |
Hierarchical Child Code |
Indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. |
Automatically entered by Intellect |
1 - additional subordinate HL data segment in this hierarchical structure |
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2010AA |
15 |
NM1 |
R |
Billing Provider Individual or Organization Name |
Contains billing provider, pay-to provider information. Although the name of this loop/segment is 'Billing Provider' the loop/segment really identifies the billing entity. The billing entity does not have to be a health care provider to use this loop. However, some payers do not accept claims from non-provider billing entities. |
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NM101 |
R |
Entity Identifier Code |
Code identifying an organizational entity, a physical location, property or an individual. 85 Billing Provider |
Automatically entered by Intellect |
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NM102 |
R |
Entity Type Qualifier |
Code qualifying the type of entity (NM102 qualifies NM103) |
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1 - Person |
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2 - Non-Person Entity |
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NM103 |
R |
Name Last or Organization Name |
Billing Provider's last name or organization name |
Utility --►Provider <Organization Name> from the code entered in Charges --► Charge <Billing Prv> |
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NM108 |
R |
Identification Code Qualifier |
If code XX is used, then FTIN must be carried in the REF section. This should be the number used for 1099's.Code identifying a party or other code (Your National Provider ID) |
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R |
Billing Provider NPI Identifier |
NPI |
If the billing method is clinic (Utility --► Set Up --► Parameter <Billing Method> = C OR L with Utility --►Category <Billing (D/C/N)> = C) this is used Utility --► Insurance <Group NPI>. If the billing method is doctor (Utility --► Set Up --► Parameter <Billing Method> = D OR L with Utility --►Category <Billing (D/C/N)> = D), based on Intellect’s selection hierarchy one of these is used: Provider Facility: <Group NPI>. Provider Provider: <Group NPI>, or Provider: <Group NPI>. |
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25 |
N3 |
R |
Address |
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30 |
N4 |
R |
CITY<STATE, ZIP |
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If the billing method is clinic (Utility --► Set Up --► Parameter <Billing Method> = C OR L with Utility --►Category <Billing (D/C/N)> = C) this is used Utility --►Set Up--► Clinic <Address>. If the billing method is doctor (Utility --► Set Up --► Parameter <Billing Method> = D OR L with Utility --►Category <Billing (D/C/N)> = D) then Utility --►Provider <Address> from the code entered in Charges --► Charge <Billing Prv>. |
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N401 |
R |
City |
Biller's City
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If the billing method is clinic (Utility --► Set Up --► Parameter <Billing Method> = C OR L with Utility --►Category <Billing (D/C/N)> = C) this is used Utility --►Set Up--► Clinic <City>. If the billing method is doctor (Utility --► Set Up --► Parameter <Billing Method> = D OR L with Utility --►Category <Billing (D/C/N)> = D) then Utility --►Provider <City> from the code entered in Charges --► Charge <Billing Prv> |
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N402 |
R |
State |
Biller's State
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If the billing method is clinic (Utility --► Set Up --► Parameter <Billing Method> = C OR L with Utility --►Category <Billing (D/C/N)> = C) this is used Utility --►Set Up--► Clinic <State>. If the billing method is doctor (Utility --► Set Up --► Parameter <Billing Method> = D OR L with Utility --►Category <Billing (D/C/N)> = D) then Utility --►Provider <State> from the code entered in Charges --► Charge <Billing Prv>. |
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N403 |
R |
Zip Code |
Biller's Zip Code
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If the billing method is clinic (Utility --► Set Up --► Parameter <Billing Method> = C OR L with Utility --►Category <Billing (D/C/N)> = C) this is used Utility --► Set Up --► Clinic <Zip Code>. If the billing method is doctor (Utility --► Set Up --► Parameter <Billing Method> = D OR L with Utility --►Category <Billing (D/C/N)> = D) then Utility --►Provider <Zip Code> from the code entered in Charges --► Charge <Billing Prv> |
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35 |
REF |
S |
Billing Prov. Secondary ID |
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REF01 |
M |
Reference Identification Qualifier |
Billing Provider Secondary Identification Number |
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REF02 |
M |
Reference Identification |
Required when a 2nd id is needed to identify Billing Provider. If XX is used in NM108/09, then FTIN or SSN must be used here |
Utility --►Provider <Box 33 1> from the code entered in Charges --► Charge <Billing Prv> |
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35 |
REF |
S |
Billing Prov. Secondary ID |
Code qualifying the Reference Identification |
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REF01 |
R |
Reference Identification Qualifier |
BQ - HMO Code Number (Vendor # - Preferred Submission) |
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G2 - Provider Commercial # (Provider ID) |
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EI - Employer's Identification # |
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SY - Social Security Number |
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Reference information as specified by the Reference ID Qualifier |
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REF02 |
R |
Reference Identification |
Tax id |
If the billing method is clinic (Utility --► Set Up --► Parameter <Billing Method> = C OR L with Utility --►Category <Billing (D/C/N)> = C) this is used Utility --► Set Up --► Clinic <IRS Number>. If the billing method is doctor (Utility --► Set Up --► Parameter <Billing Method> = D OR L with Utility --►Category <Billing (D/C/N)> = D) based on Intellect’s selection hierarchy, one of these is used: Provider Facility: <Tax ID>. Provider Provider: <Tax ID>, or Provider: <IRS ID>. If the Tax ID/IRS ID is null: Intellect sends the Utility --► Provider <Social Security No>. If sending the <Tax ID number>, the EI qualifier is submitted. If sending the <Social Security No>, the SY qualifier is submitted. |
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2000B |
1 |
HL |
M |
Subscriber Hierarchical Level |
To identify dependencies among and the content of hierarchically related groups of data segments |
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HL01 |
R |
Hierarchical ID Number |
HL01 must begin with '1' and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01. |
Automatically entered by Intellect |
2 - 2nd HL segment |
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HL02 |
R |
Hierarchical Parent ID Number |
HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. |
Automatically entered by Intellect |
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HL03 |
R |
Hierarchical Level Code |
Code defining the characteristic of a level in a hierarchical structure |
Automatically entered by Intellect |
22 - Subscriber |
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HL04 |
R |
Hierarchical Child Code |
Indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. |
Registration --► Patient --► Insurance <Relationship to Insured> |
0 - when subscriber is patient; |
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1 - when patient is a dependent of subscriber |
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5 |
SBR |
O |
Subscriber Information (SBR*P) |
Contains current insurance carrier subscriber information |
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SBR01 |
R |
Payor Responsibility Sequence Number Code |
Identifies the insurance carrier's level of responsibility for a payment of a claim |
Registration --► Patient --► Insurance <Primary/Secondary> |
P - Primary |
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S - Secondary |
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T - Tertiary or payer of last resort |
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SBR02 |
S |
Individual Relationship Code |
Use this code only when the subscriber is the same person as the patient. If the subscriber is not the same person as the patient, leave blank. |
Registration --► Patient --► Insurance <Relationship to Insured> |
18 - self |
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SBR03 |
S |
Reference Identification |
The subscriber's group number; not the subscriber # |
If there is Insurance primary to Medicare, Registration --► Patient --► Insurance screen <Group No.>, for all other cases with secondary coverage the value entered is the patient’s Registration Patient insurance screen <Group No.> |
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SBR09 |
S |
Claim Filing Indicator Code |
Code identifying type of claim. Required prior to mandated used of PlanID. Not used after PlanID is mandated |
Utility Insurance <Claim Filing Indicator> for Insurer being billed |
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2010BA |
15 |
NM1 |
O |
Subscriber's Name |
Contains subscriber's name |
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NM101 |
R |
Entity Identifier Code |
IL - Insured or Subscriber |
Automatically entered by Intellect |
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NM102 |
R |
Entity Type Qualifier |
1' = Person, '2' = Non-Person Entity |
Automatically entered by Intellect for 1 |
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NM103 |
R |
Name Last or Organization Name |
Subscriber last name or organization |
Registration Insurance <Patient Name> Or If the patient is a dependent OR a secondary claim form is being submitted AND other than self is the insured, then the name of the insured comes from the Registration --► Patient --►Insurance screen <Last Name> field. |
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NM104 |
S |
Name First |
Subscriber first name Enter into Insured Name field if Patient Relationship to Insured is not 'Self' |
Registration --► Patient --►Insurance screen, <Insured First Name>, <Middle Initial> fields. |
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NM108 |
S |
Identification Code Qualifier |
MI' automatically entered by software |
Member Identification Number. |
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NM109 |
S |
Identification Code |
Subscriber Insured ID Number |
Registration --►Patient --► Insurance <Subscriber No.>. |
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25 |
N3 |
O |
Address Information |
Address |
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N301 |
R |
Address 1 |
Subscriber's Address 1 |
If the patient is a dependent OR a secondary claim form is being submitted then the address of the insured uses the Registration --►Patient --► Insurance <Address> field. |
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30 |
N4 |
O |
Geographic Location |
City, state, zip |
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N401 |
R |
City |
Payer's City |
Registration --►Patient --► Insurance <City> |
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N402 |
R |
State |
Payer's State |
Registration --►Patient --► Insurance <State> |
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N403 |
R |
Zip Code |
Payer's Zip Code |
Registration --►Patient --► Insurance <Zip Code> |
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32 |
DMG |
O |
Subscriber's Demographic Information |
Required when the Patient is the same as the Subscriber (Loop 2000B SBR02 - 18 (self)) |
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DMG01 |
R |
Date Time Period Format Qualifier |
Indicating date format CCYYMMDD/ USES D8 |
Automatically entered by Intellect |
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DMG02 |
R |
Date Time Period |
Insured Date of Birth field if Patient Relationship to Insured |
Registration --► Patient <DOB> |
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DMG03 |
R |
Gender Code |
Insured Sex field if Patient Relationship to Insured |
Registration --► Patient <Sex (M/F/U)> |
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15 |
NM1 |
O |
Payer Name |
Contains payer information |
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NM101 |
R |
Entity Identifier Code |
Code identifying an organizational entity, a physical location, property or an individual |
Automatically entered by Intellect |
PR - Payer |
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NM102 |
R |
Entity Type Qualifier |
Code qualifying the type of entity (NM102 qualifies NM103) |
Automatically entered by Intellect |
1 - Person |
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2 - Non-Person Entity |
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NM103 |
R |
Name Last or Organization Name |
Payer's last name or organization name |
Utility --► Insurance <Name> |
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NM108 |
R |
Identification Code Qualifier |
Code designating the system/method of code structure used for the identification code. 'PI' is automatically entered by the software |
Automatically entered by Intellect |
PI - Payor ID |
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NM109 |
R |
Identification Code |
Payer ID |
Utility --► Insurance <Payer Identifier> |
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25 |
N3 |
O |
Address Information |
Address |
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N301 |
R |
Address 1 |
Payer's Address 1 |
Utility --► Insurance <Address> |
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30 |
N4 |
O |
Geographic Location |
City, state, zip |
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N401 |
R |
City |
Payer's City |
Utility --► Insurance <City> |
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N402 |
R |
State |
Payer's State |
Utility --► Insurance <State> |
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N403 |
R |
Zip Code |
Payer's Zip Code |
Utility --► Insurance <Zip Code> |
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2300 |
130 |
CLM |
R |
Health Claim |
Specifies basic data about claim header. It follows loop 2010BC when the subscriber is the patient. |
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CLM01 |
R |
Claim Submitter's Identifier |
Patient Control No. assigned by provider |
Registration --►Regular --►Patient <Patient Account No> |
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CLM02 |
R |
Monetary Amount |
Total amount of all billed charges for this claim |
The sum of all the charges for the claim from Charges --► Charge <Charge> as posted |
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CLM05 - 1 |
R |
Facility Type Code |
The first two digits of the Type of Bill Code |
Utility --► Clinic <Facility Identification Number> or, if blank, Charges --► Encounter --►UB Encounter <Bill Type> |
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CLM05 - 2 |
R |
Facility Code Qualifier |
Always 'A' Bill Type |
Hard Coded by Intellect |
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CLM05 - 3 |
R |
Claim Frequency Type Code |
Uses the third digit of the Type of Bill Code |
Utility --► Clinic <Facility Identification Number> or, if blank, Charges --► Encounter --►UB Encounter <Bill Type> |
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CLM06 |
R |
Provider Signature on File |
Indication whether provider's signature is on file. |
Utility --►Insurance <Message Box 12 & 13 > |
N-No, Y-Yes |
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R |
Provider Accept Assignment Code |
Assignment of benefits indicator. A Assigned |
If Y was entered in the Registration --►Patient --►Insurance <Assignment> field, then 'A' is used. If N was entered, then the 'C' is marked. |
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CLM08 |
R |
Benefits Assignment Certification Indicator |
Insured or authorized person authorizes benefits to be assigned to the provider. N-No, Y-Yes
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If Y was entered in the Registration --►Patient --► Insurance <Assignment> field, then 'Y' is used. If N was entered, then the 'N' is marked. If the patient's insurance screen <Assignment> field default was modified at the time of posting charges or through the Charge --►Modify screen, then the Charges --► Charge OR Charges --►Modify <ASI> value is used. |
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CLM09 |
R |
Release of Information Code |
The provider has on file a signed statement by the patient authorizing the release of medical data to other organizations. |
Entering a value in Utility --►Insurance <Message Box 12 & 13 > enters a 'Y'. |
A-appropriate release |
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I-informed consent |
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M-provider has limited ability to release data |
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N-Not allowed to release info |
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O-payor on file |
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Y-permitted to release data |
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S |
Yes/No Response Code |
Explanation of Benefits (EOB) Indicator System default 'N' |
Automatically entered by Intellect |
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CLM20 |
S |
Delay Reason Code |
Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules Administration Delay in the Prior Approval Process Other |
Charges --► Encounter --►UB Encounter <Delay Reason Code> |
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DTP 434 |
S |
Date - DOS |
Statement Date range |
Charges --►Charge <From/Date> - <To> |
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DTP 435 |
S |
Date-Admission |
Required on all ambulance claims/encounters when the patient was known to be admitted to the hospital. Also required on inpatient |
Charges --► Encounter --►UB Encounter <Admission Date> |
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CL1 is a required segment for all the |
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CL2 |
S |
Admission Source |
Required for all inpatients admissions and Medicare outpatients Registrations. |
Charges --► Encounter --►UB Encounter <Admission Source> |
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CL3 |
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Admission Status |
Required for all inpatients admissions and Medicare outpatients Registrations. |
Charges --► Encounter --►UB Encounter <Admission Status> |
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REF*G1 |
O |
Prior Authorization or Referral Number |
Prior Authorization Number |
Charges --► Encounter UB Encounter <Authorization No> |
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REF*EA |
O |
Medical Record Number |
EA Medical Record Identification Number |
Registration --► Patient <Patient Account No> |
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NTE |
O |
NOTE/Special Instruction |
To transmit information in a free-form format, if necessary, for comment or special instruction |
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363 |
NTE1 |
S |
Billing NOTE |
Qualifier DGN Diagnosis Description |
Automatically entered by Intellect |
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363 |
NTE02 |
S |
Billing NOTE |
Diagnosis Description |
Utility --► Diagnosis <Name> for the posted Diagnosis Charges--► Charge <Code> |
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363 |
NTE01 |
O |
NOTE Reference Code |
Qualifier ADD: Additional Information or DGN: Diagnosis Description. Automatically entered by Intellect |
Automatically entered by Intellect |
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352 |
NTE02 |
O |
Description |
A free-form description to clarify the related data elements and their content |
>Charges --► Encounter --►UB Encounter <Claim Notes> Medi-Cal uses this segment to convey the Emergency Certification Statement as defined by Medi-Cal policy. Emergency Services require the Emergency Certification Statement. When submitting these claims, the first five characters of the Billing NOTE Text field must be equal to EMCER. If the Emergency Certification Statement is not needed,other additional information previously sent in the CMC Remarks field may be submitted in this segment. |
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231 |
HI |
S |
Health Care Diagnosis Code |
Required on all claims/encounters except claims for which there are no diagnoses |
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HI01-1 |
R |
Code List Qualifier Code |
Qualifier BK Principal Diagnosis |
Automatically entered by Intellect |
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HI01-2 |
R |
HEALTH CARE DIAGNOSIS CODE |
The diagnosis listed in this element is assumed to be the principal diagnosis. |
Based on the Encounter entered at the time of posting (Charges --► Charge), the ICD-9/10 codes from the Charges --►Encounter--► UB Encounter <Principal Diagnosis> field for the dates of service(s) requested. |
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HI01-1 |
R |
HEALTH CARE DIAGNOSIS CODE |
Qualifier BF Other Diagnosis |
Automatically entered by Intellect |
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HI01-2 |
R |
HEALTH CARE DIAGNOSIS CODE |
Required if needed to report an additional diagnoses and if the preceding HI data elements have been used to report other diagnoses. |
Based on the order entered at the time of posting (Charges --► Charge), the ICD-9/10 code from the Utility --►Diagnosis <ICD9 Code> field for the dates of service(s) requested. |
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HI01-1 |
R |
Health Care Procedure Code |
Qualifier BP Principal Procedure |
If qualifier BP is sent, a corresponding date qualifier and date must be sent in HI01-3 and HI01-4 to Principal Procedure Information (HI) segment in the 2300 Loop |
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HI01-2 |
R |
Health Care Procedure Code |
Principal Procedure |
Based on the Encounter entered at the time of posting (Charges --► Charge), the CPT code from the Charges --►Encounter --► UB Encounter <Principal Procedure> field for the dates of service(s) requested. |
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HI01-3 |
R |
Health Care Procedure Code |
Date Qualifier |
Automatically entered by Intellect |
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HI01-4 |
R |
Health Care Procedure Code |
Principal Procedure Date |
Based on the Encounter entered at the time of posting (Charges --► Charge), the CPT code from the Charges --►Encounter --► UB Encounter <Date> field for the dates of service(s) requested. |
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HI01-1 |
S |
Occurrence Information |
Qualifier BI Occurrence Span |
Automatically entered by Intellect |
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HI01-2 |
S |
Occurrence Information |
Occurrence Span Code |
Based on the Encounter entered at the time of posting (Charges --► Charge), the Span codes from the Charges --►Encounter --► UB Encounter <Occurrence Span Code> field for the dates of service(s) requested. |
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HI01-3 |
S |
Occurrence Information |
Qualifier RD8 Date Range |
Automatically entered by Intellect |
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HI01-4 |
S |
Occurrence Information |
Span Code Associated Date Range |
Based on the Encounter entered at the time of posting (Charges --► Charge), the date range from the Charges --►Encounter --► UB Encounter <Occurrence Span From> and <Occurrence Span To>. |
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HI01-1 |
S |
Occurrence Information |
Qualifier BH Occurrence |
Automatically entered by Intellect |
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HI01-2 |
S |
Occurrence Information |
Occurrence Code |
Based on the Encounter entered at the time of posting (Charges --► Charge), Occurrence codes from the Charges --►Encounter--► UB Encounter <Occurrence Code> field for the dates of service(s) requested. |
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HI01-3 |
S |
Occurrence Information |
Qualifier D8 Date |
Automatically entered by Intellect |
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HI01-4 |
S |
Occurrence Information |
Occurrence Date |
Based on the Encounter entered at the time of posting (Charges --► Charge), the date (Occurrence) from the Charges --►Encounter --► UB Encounter <Date>. |
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HI01-1 |
S |
Value Information |
Qualifier BE Value |
Automatically entered by Intellect |
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HI01-2 |
S |
Value Information |
Value Code |
Based on the Encounter entered at the time of posting (Charges --► Charge), the Value code from the Charges --►Encounter --► UB Encounter <Value Code> field. |
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HI01-5 |
S |
Value Information |
Value Code Associated Amount |
Based on the Encounter entered at the time of posting (Charges --► Charge), the Value from the Charges --►Encounter --► UB Encounter <Amount> field. |
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HI01-1 |
S |
Condition Information |
Qualifier BG Condition |
Automatically entered by Intellect |
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HI01-2 |
S |
Condition Information |
Condition Code |
Based on the Encounter entered at the time of posting (Charges --► Charge), the Condition code from the Charges --►Encounter --► UB Encounter <Condition Code> field. |
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2310A |
NM1 |
|
Individual or Organization Name |
Contains Attending Physician information |
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|
|
98 |
NM101 |
S |
Entity Identifier Code |
71 Attending Physician |
Automatically entered by Intellect |
|
1065 |
NM102 |
S |
Entity Type Qualifier |
Code qualifying the type of entity: |
1 = Person. Automatically entered by Intellect |
|
1035 |
NM103 |
S |
Name Last or Organization Name |
Attending Physician Last Name |
|
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1036 |
NM108 |
S |
Name First |
Attending Physician First Name |
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66 |
NM108 |
S |
Identification Code Qualifier |
XX Automatically entered by Intellect |
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|
67 |
NM109 |
S |
Identification Code |
Attending Physician National Provider Identifier |
Utility --►Insurance <NPI> |
|
128 |
REF01 |
S |
Reference Identification Qualifier |
EI Employer’s Identification Number (Tax ID Qualifier) |
Automatically entered by Intellect |
|
127 |
REF02 |
S |
Reference Identification |
If the NPI is present in NM108 and NM109, then the Federal Tax Id Number is required in the REF segment. |
Utility --►Provider <Tax ID> |
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2310E |
250 |
NM1 |
R |
Individual or Organization Name |
Contains Service Facility information |
NM1 |
|
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NM101 |
R |
Entity Identifier Code |
FA - Service Facility. |
Utility --►Facility <Type> |
|
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NM102 |
R |
Entity Type Qualifier |
2 - Non-Person. |
Automatically entered by Intellect |
|
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NM103 |
R |
Name Last or Organization Name |
Service Facility Name |
Utility --►Facility <Name> |
|
66 |
NM108 |
R |
Identification Code Qualifier |
XX Automatically entered by Intellect |
Automatically entered by Intellect |
|
67 |
NM109 |
R |
Identification Code |
Facility National Provider Identifier |
Utility --►Facility <NPI> |
|
265 |
N3 |
R |
Address Information |
|
|
|
166 |
N301 |
R |
Address 1 |
Service Facility's Address 1 |
Utility --►Facility <Address> |
|
270 |
N4 |
O |
Geographic Location |
City, state, zip |
|
|
|
N401 |
R |
City |
Service Facility's City |
Utility --►Facility <City> |
|
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N402 |
R |
State |
Service Facility's State |
Utility --►Facility <Zip State> |
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N403 |
R |
Zip Code |
Service Facility's Zip Code |
Utility --►Facility <Zip Code> |
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2320 |
318 |
SBR |
S |
OTHER SUBSCRIBER INFORMATION |
Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber, Subscriber of the Other Insurance Carriers, School, or Employer Information for that Subscriber. |
|
|
1138 |
SBR01 |
R |
Payer Responsibility Sequence Number Code |
P Primary S Secondary T Tertiary |
Registration --► Patient --► Insurance <Primary/Secondary> |
|
1069 |
SBR02 |
R |
Patient Relationship to Insured |
18 Self |
Registration --► Patient --► Insurance <Relationship to Insured> |
|
83 |
SBR03 |
S |
Insured Group or Policy Number |
Required if the subscriber’s payer identification includes Group or Plan Number. This data element is intended to carry the subscriber’s Group Number, not the number that uniquely identifies the subscriber |
Registration --► Patient secondary insurance <Subscriber Number> |
|
93 |
SBR04 |
S |
Other Insured Group or Policy Name |
Required if the subscriber’s payer identification includes a Group or Plan Name |
Registration --► Patient Insurance <Type> for the secondary insurance screen |
|
1336 |
SBR05 |
R |
Insurance Type Code |
Code identifying the type of insurance policy within a specific insurance program |
Registration --► Patient Insurance <Claim Filing Indicator> for the secondary insurance screen |
|
1032 |
SBR09 |
S |
Claim filing indicator code |
Required when using Plan ID |
Registration --► Patient Insurance <Company Name> field for secondary insurance screen |
|
|
DMG |
S |
Subscriber Demographic Information |
|
|
|
1250 |
DMG01 |
R |
Date Time Period Format Qualifier |
D8 |
Automatically entered by Intellect |
|
1251 |
DMG02 |
R |
Date Time Period |
Other Insured Birth Date |
If the patient is the insured, the date of birth comes from the Registration --► Patient <DOB> field. If the patient is a dependent, the date of birth comes from the Registration --► Patient --►Insurance <Insured DOB> |
|
1068 |
DMG03 |
R |
Gender Code |
Other Insured Gender Code |
If the patient is the insured, the gender comes from the Registration --► Patient <Gender> field. If the patient is a dependent, the gender comes from the Registration --► Patient --►Insurance <Gender> |
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OI |
R |
Other Insurance Coverage Information |
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|
1073 |
OI03 |
R |
Yes/No Condition or Response Code |
The assignment of benefits indicator. A 'Y' value indicates insured or authorized person authorizes benefits to be assigned to the provider; an 'N' value indicates benefits have not been assigned to the provider. |
If Y has been entered in the Registration --►Patient --►Insurance <Assignment> field for the secondary insurance, then 'Y' is used. If N has been entered, then the 'N' is marked. If the patient's secondary insurance screen <Assignment> field default was modified at the time of posting charges or through the Charge --►Modify screen, then the Charges --►Charge OR Charges --►Modify <ASI> value is used. |
|
1351 |
OI04 |
S |
Patient Signature Source Code |
Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider |
Entering a value in Utility --►Insurance <Message Box 12 & 13> enters a 'Y' |
|
1363 |
OI06 |
R |
Release of Information Code |
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations |
Entering a value in Utility --►Insurance <Message Box 12 & 13> enters a 'Y' |
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|
2330A |
|
|
R |
OTHER SUBSCRIBER NAME |
|
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|
2330 |
NM1 |
O |
Individual or Organizational Name |
Segments NM1-N4 contain patient name and address information of the insurance carriers referenced in loop 2320. |
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|
98 |
NM101 |
R |
Entity Identifier Code |
Code identifying an organizational entity, a physical location, property or an individual. Automatically entered by Intellect IL = Subscriber |
Automatically entered by Intellect |
|
1065 |
NM102 |
R |
Entity Type Qualifier |
Automatically entered by Intellect 1 = Person |
Automatically entered by Intellect |
|
1035 |
NM103 |
R |
Name Last or Organization Name |
Other Insured Last Name |
If the patient is the insured, Last Name comes from the Registration --► Patient --► <Last Name> field. If the patient is a dependent, the Last Name comes from the Registration --► Patient --►Insurance <Last Name> for the secondary insurance |
|
1036 |
NM104 |
R |
Name First |
Other Insured First Name |
If the patient is the insured, First Name comes from the Registration --► Patient --► <First Name> field. If the patient is a dependent, the Last Name comes from the Registration --► Patient --►Insurance <Insured First Name> for the secondary insurance |
|
66 |
NM108 |
R |
Identification Code Qualifier |
The code MI is intended to be the subscriber’s identification number as assigned by the payer. Payers use different terminology to convey the same number. |
|
|
67 |
NM109 |
R |
Identification Code |
Other Subscriber Primary Identifier |
Utility --►Insurance <Subscriber No> for Registration --► Patient secondary insurance |
|
|
N3 |
O |
Address Information |
|
|
|
166 |
N301 |
R |
Address Information |
Other Insured Address Line |
If the patient is the insured, the address comes from the Registration --► Patient --► <Address> field. If the patient is a dependent, the address comes from the Registration --► Patient --►Insurance <Address> for the secondary insurance |
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|
N4 |
O |
Geographic Location |
|
|
|
19 |
N401 |
S |
City Name |
Other Insured City Name |
If the patient is the insured, the city name comes from the Registration --► Patient --► <City> field. If the patient is a dependent, the city name comes from the Registration --► Patient --►Insurance <City> for the secondary insurance |
|
156 |
N402 |
S |
State or Province Code |
Other Insured State Code |
If the patient is the insured, the state name comes from the Registration --► Patient --► <State> field. If the patient is a dependent, the state name comes from the Registration --► Patient --►Insurance <State> for the secondary insurance |
|
116 |
N403 |
S |
Postal Code |
Other Insured Postal Zone or ZIP Code |
If the patient is the insured, the Zip code comes from the Registration --► Patient --► <Zip Code> field. If the patient is a dependent, the Zip code comes from the Registration --► Patient --►Insurance <Zip Code> for the secondary insurance |
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|
2330B * |
|
|
R |
OTHER PAYER NAME |
Submitters are required to send all known information on other payers in this Loop ID-2330. |
|
|
325 |
NM1 |
R |
Individual or Organizational Name |
To supply the full name of an individual or organizational entity |
|
|
98 |
NM101 |
R |
Entity Identifier Code |
Code identifying an organizational entity, a physical location, property or an Individual PR= Payer |
|
|
1065 |
NM102 |
R |
Entity Type Qualifier |
2 = Non-Person Entity |
|
|
1035 |
NM103 |
R |
Name Last or Organization Name |
Other Payer Last or Organization Name |
Registration --►Patient --► Insurance <Insurance Company Name> for the secondary insurance |
|
66 |
NM108 |
R |
Identification Code Qualifier |
PI Payor Identification |
Automatically entered by Intellect |
|
NM109 |
R |
Identification Code |
|
|
|
|
|
REF*F8 |
S |
Original Reference Number |
Original Reference Number |
Charges --► Encounter UB Encounter <Internal Control> |
* April 2011: In regard to LA County Mental Health Billing, the client has to send the 2330B DTP01 573 (date claim paid) in the 837 (th_payment_date) to qualify for payment from them. |
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|
2400 |
|
|
R |
SERVICE LINE |
The Service Line LX segment begins with 1 and is incremented by one for each additional service line of a claim. The LX functions as a line counter. |
|
|
|
LX01 |
R |
LX Assigned Number |
The service line number incremented by 1 for each service line. |
Automatically entered by Intellect |
|
|
SV2 |
R |
Institutional Service Line |
To specify the claim service detail for a Health Care Institution |
|
|
235 |
SV202-1 |
R |
Product/Service ID Qualifier |
HC = Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
Automatically entered by Intellect |
|
234 |
SV202 - 2 |
R |
Product/Service ID Qualifier |
Procedure Code |
Based on the patient’s assigned insurance Utility --►Insurance <Code (R/C/E/U)> field entry, the corresponding code from Utility --►Procedure <Code R>, <Code C>,<Code E>, <Revenue Code> entered at the time of posting the panel code (Charges --► Charge) is used here. |
|
762 |
SV203 |
R |
Monetary Amount |
Submitted charge amount |
This uses the amount from the posted Charges --►Charge <Charge>. |
|
355 |
SV204 |
R |
Unit or Basis for Measurement Code |
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken. UN = Unit |
Automatically entered by Intellect |
|
380 |
SV205 |
R |
Quantity |
Units or Minutes |
The value entered in the Utility --►Procedure <Days & Units> field is used. If this value is modified at the time of posting, then the Charges --►Charge <Qty> entry is used. |
|
|
SE |
R |
|
Transaction Set Trailer |
|
|
|
SE01 |
R |
|
Transaction Segment Count |
Automatically entered by Intellect |
|
|
SE02 |
R |
|
Transaction Set Control Number |
Automatically entered by Intellect |
|
|
GE |
R |
Functional Group Trailer |
To indicate the end of a functional group and to provide control information |
Automatically entered by Intellect |
|
|
GE01 |
R |
Functional Group Trailer |
Number of Transaction Sets Included |
Automatically entered by Intellect |
|
|
GE02 |
R |
Functional Group Trailer |
Sender Assigned Control Number |
Automatically entered by Intellect |
|
|
IEA |
R |
Interchange Control Trailer |
To define the end of an interchange of zero or more functional groups and interchange-related control segments |
Automatically entered by Intellect |
|
|
IEA01 |
R |
Interchange Control Trailer |
Number of Included Functional Groups |
Automatically entered by Intellect |
|
|
IEA02 |
R |
Interchange Control Trailer |
Interchange Control Number |
Automatically entered by Intellect |
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