OnSTAFF 2000
April 2, 2009
Procedure Set Up:
Encounter RX Number:
Charge/Add:
Example of Professional Electronic Billing (Claim Type 2) and HCFA form with NDC information:
ISA*00* *00* *ZZ*MCARSUB *ZZ*31146 *090402*2236*U*00401*000001737*1*P*:
GS*HC*MCARSUB**20090402*2236*1737*X*004010X098A1
ST*837*1738
BHT*0019*00*1739*20090402*2236*CH
REF*87*004010X098A1
NM1*41*2*PCS ONSTAFF SERVER 28*****46*MCARSUB
PER*IC*Support Login – don’t change*TE*6264491705
NM1*40*2*MEDICARE NHIC*****46
HL*1**20*1
NM1*85*2*KIDNEY CENTER - HOME HEALTH*****XX*PP GRP NPI
N3*PROV ADDRESS
N4*PASADENA*CA*911079110
REF*SY*222222222
HL*2*1*22*0
SBR*P*18*******MB
NM1*IL*1*NDC*TEST****MI*123135154A
N3*1029 WILSON ST
N4*PASADENA*CA*91102
DMG*D8*19250415*F
NM1*PR*2*MEDICARE NHIC*****PI*31146
N3*PO BOX 54297
N4*SOUTH PASADENA*CA*91030
CLM*242*1800***11::1*Y*A*Y*Y*B
REF*EA*242
HI*BK:78900
NM1*DN*1*SIMMONS*TIMOTHY****XX*SIMMONSNPI
NM1*FA*2*FACILITY NAMEE*****XX*FANPI
N3*FACILITY ADDRESS
N4*GLENDALE*CA*91205 **PROFESSIONAL BILLING WITHOUT RX#**
LX*1
SV1*HC:J1234*1800*UN*60*11**1 1800 = Charge Amount | UN = Proc Unit of Measurement | 60 = Charge Units
DTP*472*D8*20090301
REF*6R*14209
LIN**N4*NDC45678901 N4 – NDC Qualifier | NDC45678901 = Procedure NDC 11 character number
CTP***800*1.2*UN 800 = Proc Cost | 1.2= Charge Units divided by Proc NDC Unit | Un = Proc Unit of Measure
HL*3**20*1
NM1*85*2*ORGANIZATION NAME*****XX*PP4GRP NPI
N3*3675 E HUNTINGTON DR A
N4*PASADENA*CA*911071234
REF*SY*123456789
HL*4*3*22*0
SBR*P*18*******MB
NM1*IL*1*NDC*TEST****MI*123135154A
N3*1029 WILSON ST
N4*PASADENA*CA*91102
DMG*D8*19250415*F
NM1*PR*2*MEDICARE NHIC*****PI*31146
N3*PO BOX 54297
N4*SOUTH PASADENA*CA*91030
CLM*242*1800***11::1*Y*A*Y*Y*B
REF*EA*242
HI*BK:78900
NM1*DN*1*BUCKLEY*FRANK****XX*PrvNPI
NM1*82*1*BUCKLEY*FRANK*A***XX*PrvNPI
NM1*FA*2*FACILITY NAMEE*****XX*FANPI
N3*FACILITY ADDRESS
N4*GLENDALE*CA*91205 **PROFESSIONAL BILLING WITH RX#**
LX*1
SV1*HC:J1234*1800*UN*60*11**1 1800 = Charge Amount | UN = Proc Unit of Measurement | 60 = Charge Units
DTP*472*D8*20090315
REF*6R*14208
LIN**N4*NDC45678901 N4 – NDC Qualifier | NDC45678901 = Procedure NDC 11 character number
CTP***800*1.2*UN 800 = Proc Cost | 1.2= Charge Units divided by Proc NDC Unit | Un = Proc Unit of Measure
REF*XZ*1234567890 XZ = Rx Qualifier | 1234567890 = Encounter 10 digit Rx number
SE*63*1738
GE*1*1737
IEA*1*000001737
The Rx number is not printed on the paper claim.
April 2, 2009
Example of Institutional Electronic Billing (Claim Type 1) and UB04 form with NDC information:
ISA*00* *00* *ZZ*MCARSUB *ZZ*31146 *090402*2236*U*00401*000001740*1*P*:
GS*HC*MCARSUB**20090402*2236*1740*X*004010X098A1
ST*837*1741
BHT*0019*00*1742*20090402*2236*CH
REF*87*004010X098A1
NM1*41*2*PCS ONSTAFF SERVER 28*****46*MCARSUB
PER*IC*Support Login – don’t change*TE*6264491705
NM1*40*2*MEDICARE NHIC*****46
HL*1**20*1
NM1*85*2*KIDNEY CENTER - HOME HEALTH*****XX*PP GRP NPI
N3*PROV ADDRESS
N4*PASADENA*CA*911079110
REF*SY*222222222
HL*2*1*22*0
SBR*P*18*******MA
NM1*IL*1*NDC*TEST****MI*123135154A
N3*1029 WILSON ST
N4*PASADENA*CA*91102
DMG*D8*19250415*F
NM1*PR*2*MEDICARE NHIC*****PI*31146
N3*PO BOX 54297
N4*SOUTH PASADENA*CA*91030
CLM*242*1800***34:A:5*Y*A*Y*Y*********N
DTP*434*RD8*20090301-20090301
REF*EA*242
NTE*DGN*ABDOMINAL PAIN
HI*BK:78900
HI*BF:78900
NM1*71*2*SIMMONS TIMOTHY M
NM1*FA*2*FACILITY NAMEE*****XX*FANPI
N3*FACILITY ADDRESS
N4*GLENDALE*CA*91205 **INSTITUTIONAL BILLING WITHOUT RX#**
LX*1
SV2**HC:J1234*1800*UN*60 1800 = Charge Amount | UN = Proc Unit of Measurement | 60 = Charge Units
DTP*472*D8*20090301
LIN**N4*NDC45678901 N4 – NDC Qualifier | NDC45678901 = Procedure NDC 11 character number
CTP***800*1.2*UN 800 = Proc Cost | 1.2 Proc Charge Units divided by NDC Unit | Un = Proc Unit of Measure
HL*3**20*1
NM1*85*2*ORGANIZATION NAME*****XX*PP4GRP NPI
N3*3675 E HUNTINGTON DR A
N4*PASADENA*CA*911071234
REF*SY*123456789
HL*4*3*22*0
SBR*P*18*******MA
NM1*IL*1*NDC*TEST****MI*123135154A
N3*1029 WILSON ST
N4*PASADENA*CA*91102
DMG*D8*19250415*F
NM1*PR*2*MEDICARE NHIC*****PI*31146
N3*PO BOX 54297
N4*SOUTH PASADENA*CA*91030
CLM*242*1800***34:A:1*Y*A*Y*Y*********N
DTP*434*RD8*20090315-20090315
REF*EA*242
NTE*DGN*ABDOMINAL PAIN
HI*BK:78900
HI*BF:78900
NM1*71*1*BUCKLEY*FRANK****XX*PrvNPI
NM1*FA*2*FACILITY NAMEE*****XX*FANPI
N3*FACILITY ADDRESS
N4*GLENDALE*CA*91205 **INSTITUTIONAL BILLING WITH RX#**
LX*1
SV2**HC:J1234*1800*UN*60 1800 = Charge Amount | UN = Proc Unit of Measurement | 60 = Charge Units
DTP*472*D8*20090315
LIN**N4*NDC45678901 N4 – NDC Qualifier NDC45678901 = Procedure NDC 11 character number
CTP***800*1.2*UN 800 = Proc Cost | 1.2= Charge Units divided by Proc NDC Unit | Un = Proc Unit of Measure
REF*XZ*1234567890 XZ = Rx Qualifier | 1234567890 = Encounter 10 digit Rx number
SE*66*1741
GE*1*1740
IEA*1*000001740
The Rx number is not printed on the paper claim.