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OnSTAFF 2000

837 Health Care Claim Institutional Review

Due to the width of this grid view as 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

LOOP

POSITION

SEGMENT ID

X-12

SEGMENT NAME

NOTES

 Located in Intellect Software

ISA

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

GS

R

Functional Group Header

Indicates the beginning of a functional group and provides control information

Automatically entered by Intellect

5

ST

R

Transaction Set Header

Start transaction set and assign a control number

Automatically entered by Intellect

10

BHT

R

Beginning Hierarchy Transaction

Indicates beginning of a transaction set

Automatically entered by Intellect

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

BHT02

R

Transaction Set Purpose Code

Identify purpose of the 837 transaction set

Automatically entered by Intellect

BHT03

R

Reference Identification

Number assigned by the originator to identify the transaction within the originator's business application system.

Automatically entered by Intellect

BHT04

R

Date

Date of transaction creation

Automatically entered by Intellect

BHT05

R

Time

Time of transaction creation

Automatically entered by Intellect

BHT06

R

Transaction Type Code

Specifies the type of transaction:  claims or encounters

Automatically entered by Intellect

15

REF

R

Transmission Type Identification

Specifies identifying information

Automatically entered by Intellect

REF01

R

Reference Identification Qualifier

Code qualifying the Reference Identification

Automatically entered by Intellect

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

1000A

20

NM1

R

Submitter Name

To supply the full name of an individual or organizational entity

NM101

R

Entity Identifier Code

Code identifying an organizational entity, a physical location, property or an individual

Automatically entered by Intellect

NM102

R

Entity Type Qualifier

Code qualifying the type of entity (NM102 qualifies NM103)

Automatically entered by Intellect

NM103

R

Name Last or Organization Name

Submitter's last name or organizational name

Utility --►Set Up --► Clinic <Name>

NM108

R

Identification Code Qualifier

Code designating the system/method of code structure used for the identification code. 46 Electronic Transmitter Identification Number (ETIN)

Automatically entered by Intellect

45

PER

R

Submitter EDI Contact Information

Contact person from submitter organization.

PER01

R

Contact Function Code

Code identifying the major duty or responsibility of the person or group named

Automatically entered by Intellect

PER02

R

Name

Free-form name of contact

Utility --►Set Up --►Security --► Login Users <Operator Name>

PER03

R

Communication Number Qualifier

Code identifying the type of communication number

Telephone Automatically entered by Intellect

PER04

R

Communication Number

Complete communications number including area code

Utility --►Set Up --► Clinic <Phone>

1000B

20

NM1

R

Receiver Name

NM101

R

Entity Identifier Code

Code identifying an organizational entity, a physical location, property or an individual

Automatically entered by Intellect

NM102

R

Entity Type Qualifier

Code qualifying the type of entity (NM102 qualifies NM103)

Automatically entered by Intellect

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>

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

NM109

R

Identification Code

Code identifying a party or other code

Utility --► Insurance <Receiver Code>

2000A

1

HL

R

Billing/Pay-To Provider Hierarchical Level

To identify dependencies among and the content of hierarchically related groups of data segments

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

HL03

R

Hierarchical Level Code

Code defining the characteristic of a level in a hierarchical structure

Automatically entered by Intellect

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

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.

NM101

R

Entity Identifier Code

Code identifying an organizational entity, a physical location, property or an individual. 85 Billing Provider

Automatically entered by Intellect

NM102

R

Entity Type Qualifier

Code qualifying the type of entity (NM102 qualifies NM103)

NM103

R

Name Last or Organization Name

Billing Provider's last name or organization name

Utility --►Provider <Organization Name> from the code entered Charges --► Charge <Billing Prv>

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)

NM109

R

Billing Provider Identifier

NPI

If your billing method is clinic (Utility --► Set Up --► Parameter <Billing Method> = C OR L with Utility --►Category <Billing (D/C/N)> = C) the following will be used Utility --► Insurance <Group NPI>. If your 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 the following will be used: Provider Facility: <Group NPI>. Provider Provider: <Group NPI>, or Provider: <Group NPI>.

30

N4

R

Geographic Location

City, state, zip

N401

R

City

Biller's City

If your billing method is clinic (Utility --► Set Up --► Parameter <Billing Method> = C OR L with Utility --►Category <Billing (D/C/N)> = C) the following will be used Utility --►  Set Up  --► Clinic <City>   If your 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 Charges --► Charge <Billing Prv>

N402

R

State

Biller's State

If your billing method is clinic (Utility --► Set Up --► Parameter <Billing Method> = C OR L with Utility --►Category <Billing (D/C/N)> = C) the following will be used Utility --►  Set Up  --► Clinic <State>   If your 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 Charges --► Charge <Billing Prv>

N403

R

Zip Code

Biller's Zip Code

If your billing method is clinic (Utility --► Set Up --► Parameter <Billing Method> = C OR L with Utility --►Category <Billing (D/C/N)> = C) the following will be used Utility --►  Set Up  --► Clinic <Zip Code>   If your 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 Charges --► Charge <Billing Prv>

35

REF

S

Billing Prov. Secondary ID

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

Automatically entered by Intellect

REF01

M

Reference Identification Qualifier

Billing Provider Secondary Identification Number

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 Charges --► Charge <Billing Prv>

35

REF

S

Billing Prov. Secondary ID

Code qualifying the Reference Identification

REF01

R

Reference Identification Qualifier

BQ - HMO Code Number (Vendor # - Preferred Submission)

REF02

R

Reference Identification

Tax id

If your billing method is clinic (Utility --► Set Up --► Parameter <Billing Method> = C OR L with Utility --►Category <Billing (D/C/N)> = C) the following will be used Utility --► Set Up --► Clinic <IRS Number>. If your 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 the following will be 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>: EI qualifier is submitted.  If sending the <Social Security No> the SY qualifier is submitted.

2000B

1

HL

M

Subscriber Hierarchical Level

To identify dependencies among and the content of hierarchically related groups of data segments

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

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

HL03

R

Hierarchical Level Code

Code defining the characteristic of a level in a hierarchical structure

Automatically entered by Intellect

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>

5

SBR

O

Subscriber Information (SBR*P)

Contains current insurance carrier subscriber information

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>

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>

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.> All other cases with secondary coverage the value entered on the patient’s Registration Patient insurance screen <Group No.>

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

2010BA

15

NM1

O

Subscriber's Name

Contains subscriber's name

NM101

R

Entity Identifier Code

IL - Insured or Subscriber

Automatically entered by Intellect

NM102

R

Entity Type Qualifier

1' = Person, '2' = Non-Person Entity

Automatically entered by Intellect for 1

NM103

R

Name Last or Organization Name

Subscriber last name or organization

Registration Insurance <Patient Name> Or If the patient is a dependent OR  you are submitting a secondary claim form AND other than self is the insured, then the name of the insured will come from the Registration --► Patient --►Insurance screen <Last Name> field.

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.

NM108

S

Identification Code Qualifier

MI' automatically entered by software

Member Identification Number

NM109

S

Identification Code

Subscriber Insured ID Number

Registration --►Patient --► Insurance screen <Subscriber No.> field.

25

N3

O

Address Information

Address

N301

R

Address 1

Subscriber's Address 1

If the patient is a dependent OR you are submitting a secondary claim form then the address of the insured will use the Registration --►Patient --► Insurance <Address> field.

30

N4

O

Geographic Location

City, state, zip

N401

R

City

Payer's City

Registration --►Patient --► Insurance  <City>

N402

R

State

Payer's State

Registration --►Patient --► Insurance <State>

N403

R

Zip Code

Payer's Zip Code

Registration --►Patient --► Insurance <Zip Code>

32

DMG

O

Subscriber's Demographic Information

Required when the Patient is the same as the Subscriber (Loop 2000B SBR02 - 18 (self))

DMG01

R

Date Time Period Format Qualifier

Indicating date format CCYYMMDD/ USES D8

Automatically entered by Intellect

DMG02

R

Date Time Period

Insured Date of Birth field if Patient Relationship to Insured

Registration --► Patient <DOB>

DMG03

R

Gender Code

Insured Sex field if Patient Relationship to Insured

Registration --► Patient <Sex (M/F/U)>

2010BC

15

NM1

O

Payer Name

Contains payer information

NM101

R

Entity Identifier Code

Code identifying an organizational entity, a physical location, property or an individual

Automatically entered by Intellect

NM102

R

Entity Type Qualifier

Code qualifying the type of entity (NM102 qualifies NM103)

Automatically entered by Intellect

NM103

R

Name Last or Organization Name

Payer's last name or organization name

Utility --► Insurance <Name>

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

NM109

R

Identification Code

Payer ID

Utility --► Insurance <Payer Identifier>

25

N3

O

Address Information

Address

N301

R

Address 1

Payer's Address 1

Utility --► Insurance <Address>

30

N4

O

Geographic Location

City, state, zip

N401

R

City

Payer's City

Utility --► Insurance <City>

N402

R

State

Payer's State

Utility --► Insurance <State>

N403

R

Zip Code

Payer's Zip Code

Utility --► Insurance <Zip Code>

2300

130

CLM

R

Health Claim

Specifies basic data about claim header. Will follow loop 2010BC when subscriber is the patient.

CLM01

R

Claim Submitter's Identifier

Patient Control No. assigned by provider

Registration --►Regular --►Patient <Patient Account No>

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

CLM05 - 1

R

Facility Type Code

The first two digits of the Type of Bill Code

Utility --► Clinic <Facility Identification Number> of if blank Charges --► Encounter  --►UB Encounter <Bill Type>

CLM05 - 2

R

Facility Code Qualifier

Always "A" Bill Type

Hard Coded by Intellect

CLM05 - 3

R

Claim Frequency Type Code

Uses the third digit of the Type of Bill Code

Utility --► Clinic <Facility Identification Number> of if blank Charges --► Encounter  --►UB Encounter <Bill Type>

CLM06

R

Provider Signature on File

Indication whether provider's signature is on file.

Utility --►Insurance < Message Box 12 & 13 >

CLM07

R

Provider Accept Assignment Code

Assignment of benefits indicator. A Assigned
C Not Assigned

If Y has been entered in the Registration -►Patient-► Insurance<Assignment> field, then “A” will be used. If N has been entered, then the “C” will be marked.

CLM08

R

Benefits Assignment Certification Indicator

Insured or authorized person authorizes benefits to be assigned to the provider.

If Y has been entered in the Registration -►Patient-► Insurance<Assignment> field,then “Y” will be used. If N has been entered, then the “N” will be 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 will be used.

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 > will enter a "Y"

CLM18

S

Yes/No Response Code

Explanation of Benefits (EOB) Indicator System default "N"

Automatically entered by Intellect

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>

DTP 434

S

Date - DOS

Statement Date range

Charges --►Charge <From/Date> -<To>

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
medical visits claims/encounters.

Charges --► Encounter --►UB Encounter <Admission Date>

CL1 is a required segment for all the

CL2

S

Admission Source

Required for all inpatients admissions and Medicare outpatients Registrations.

Charges --► Encounter --►UB Encounter <Admission Source>

CL3

Admission Status

Required for all inpatients admissions and Medicare outpatients Registrations.

Charges --► Encounter --►UB Encounter <Admission Status>

REF*G1

O

Prior Authorization or Referral Number

Prior Authorization Number

Charges --► Encounter UB Encounter <Authorization No>

REF*EA

O

Medical Record Number

EA Medical Record Identification Number

Registration  --► Patient <Patient Account No>

NTE

O

Note/Special Instruction

To transmit information in a free-form format, if necessary, for comment or special instruction

363

NTE1

S

Billing Note

Qualifier DGN Diagnosis Description

Automatically entered by Intellect

363

NTE02

S

Billing Note

Diagnosis Description

Utility --► Diagnosis <Name> for the posted Diagnosis Charges --► Charge <Code>

363

NTE01

O

Note Reference Code

Qualifier ADD: Additional Information or DGN: Diagnosis Description. Automatically entered by Intellect

Automatically entered by Intellect

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 will use 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.

231

HI

S

Health Care Diagnosis Code

Required on all claims/encounters except claims for which there are no diagnoses

HI01-1

R

Code List Qualifier Code

Qualifier BK Principal Diagnosis

Automatically entered by Intellect

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 codes from the Charges --►Encounter  --► UB Encounter <Principal Diagnosis> field for the dates of service(s) requested.

HI01-1

R

HEALTH CARE DIAGNOSIS CODE

Qualifier BF Other Diagnosis

Automatically entered by Intellect

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 code from the Utility --►Diagnosis <ICD9 Code> field for the dates of service(s) requested.

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

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.

 HI01-3

R

Health Care Procedure Code

Date Qualifier

Automatically entered by Intellect

 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.

HI01-1

S

Occurrence Information

Qualifier BI Occurrence Span

Automatically entered by Intellect

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.

HI01`-3

S

Occurrence Information

Qualifier RD8 Date Range

Automatically entered by Intellect

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>.

HI01-1

S

Occurrence Information

Qualifier BH Occurrence

Automatically entered by Intellect

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.

HI01-3

S

Occurrence Information

Qualifier D8 Date

Automatically entered by Intellect

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>.

HI01-1

S

Value Information

Qualifier BE Value

Automatically entered by Intellect

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 .

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 .

HI01-1

S

Condition Information

Qualifier BG Condition

Automatically entered by Intellect

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 .

2310A

250

NM1

Individual or Organization Name

Contains Attending Physician  information

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

1036

NM108

S

Name First

Attending Physician First Name

66

NM108

S

Identification Code Qualifier

XX Automatically entered by Intellect

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>

2310E

250

NM1

R

Individual or Organization Name

Contains Service Facility information

NM1

NM101

R

Entity Identifier Code

FA - Service Facility.

Utility --►Facility<Type>

NM102

R

Entity Type Qualifier

2 - Non-Person.

 Automatically entered by Intellect

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>

N402

R

State

Service Facility's State

Utility --►Facility<Zip State>

N403

R

Zip Code

Service Facility's Zip Code

Utility --►Facility<Zip Code>

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 screen <Primary/Secondary>

1069

SBR02

R

Patient Relationship to Insured

18 Self

Registration --► Patient --► Insurance screen <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 screen <Subscriber Number> field.

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> field for 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> field for 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 will come from the Registration --► Patient --► <DOB> field. If the patient is a dependent, the date of birth will come from the Registration --► Patient --►Insurance <Insured DOB>

1068

DMG03

R

Gender Code

Other Insured Gender Code

If the patient is the insured, the gender will come from the Registration --► Patient --► <Gender> field. If the patient is a dependent, the gender will come from the Registration --► Patient --►Insurance <Gender>

OI

R

Other Insurance Coverage Information

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” will be used. If N has been entered, then the “N” will be 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 will be 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 Utility --►Insurance < Message Box 12 & 13 > will enter 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 Utility --►Insurance < Message Box 12 & 13 > will enter a "Y"

2330A

R

OTHER SUBSCRIBER NAME 

2330

NM1

O

Individual or Organizational Name

Segments NM1-N4 contain patient name and address information of the insurance carriers referenced in loop 2320.

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 will come from the Registration --► Patient --► <Last Name> field. If the patient is a dependent, the Last Name will come 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 will come from the Registration --► Patient --► <First Name> field. If the patient is a dependent, the Last Name will come 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 will come from the Registration --► Patient --► <Address> field. If the patient is a dependent, the address will come from the Registration --► Patient --►Insurance <Address> for the secondary insurance

N4

O

Geographic Location

19

N401

S

City Name

Other Insured City Name

If the patient is the insured, the city name will come from the Registration --► Patient --► <City> field. If the patient is a dependent, the city name will come 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 will come from the Registration --► Patient --► <State> field. If the patient is a dependent, the state name will come 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 will come from the Registration --► Patient --► <Zip Code> field. If the patient is a dependent, the Zip code will come from the Registration --► Patient --►Insurance <Zip Code> for the secondary insurance

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

67

NM109

R

Identification Code

REF*F8

S

Original Reference Number

Original Reference Number

Charges --► Encounter UB Encounter <Internal Control>

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) will be used here

762

SV203

R

Monetary Amount

Submitted charge amount

This will use 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 will be used. If this value is modified at the time of posting, then the Charges --►Charge <Qty> entry will be 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