ANSI ASC X12N 837 Healthcare Claim Institutional, Professional and Dental Department of Labor-OWCP Companion Guide

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1 Institutional, Professional and Dental Department of Labor-OWCP Companion Guide May 31, 2017

2 TABLE OF CONTENTS AT A GLANCE II CHAPTER 1 INTRODUCTION 1 Audience 1 CHAPTER 2 TRANSMISSION METHODS 2 Communication Protocols 2 Teleprocessing Requirements 2 Teleprocessing Settings 3 Transmission Procedures 4 Web Portal 6 Mainframe-to-Mainframe Connections 6 Network Data Mover (NDM) and 6 Tape Cartridge 8 CHAPTER 3 TRANSMISSION RESPONSES 9 Interchange Level Errors and TA1 Rejection Report 9 TA1-Interchange Acknowledgement 9 Transaction Set Level Syntax Results and 999 Rejection Report Functional Acknowledgement Remittance Advice 12 Host Bulletin Board System 12 CHAPTER 4 DATA RETRIEVAL METHODS 13 WEB PORTAL 13 HOST Bulletin Board System 13 CHAPTER 5 TESTING 14 Trading Partner Testing Procedures 14 CHAPTER 6 PAYER SPECIFIC DATA 16 EDI Support 16 Enrollment Information 16 Transmission Telephone Number 16 Tracking Transmission/Production Problems 17 Highlights 17 CHAPTER 7 TRANSACTION DESCRIPTION - V5010.A Professional Dental Institutional 46 5/6/2010 ii

3 At a Glance Chapter 1, Introduction Chapter 1 includes a brief overview of Conduent EDI Solutions and the services it provides (pages 1 & 2). Chapter 2, Transmission Methods Chapter 2 discusses the asynchronous dial-up method of electronic data interchange with Conduent EDI Solutions (pages 3-6). Chapter 3, Transmission Responses Chapter 3 discusses confirmation and error responses to transactions submitted (pages 7-12). Chapter 4, Data Retrieval Methods Chapter 4 highlights various means of electronic data interchange retrieval from the Conduent EDI Solutions (page 13). Chapter 5, Testing Chapter 5 discusses transaction-testing procedures (page 14). Chapter 6, Payer Specific Data Chapter 6 includes information on Enrollment and CONDUENT EDI Support Unit contact information (pages 15 & 16). Chapter 7, Transaction Description - V5010.A1 Chapter 7 offers Department of Labor -specific data clarification for developers to use in conjunction with the ANSI X12N Implementation Guides (pages 17-19). 5/6/2010 1

4 Chapter 1 Introduction Conduent EDI Solutions, Inc., a leader in healthcare technology, provides EDI Gateway services to providers enrolled in contracted healthcare plans. Our electronic transactions acquisition services provide an array of tools that allow you to: Easily submit all of your transactions to one source Submit transactions twenty-four hours a day, seven days a week Receive confirmation of receipt of each file transferred Receive remittance notification from health care plans on a regular basis Healthcare plans that participate with Conduent EDI Solutions, Inc. are referred to as payers. Transactions are accepted electronically and are processed through the Conduent State Healthcare Clearinghouse (SHCH). As an EDI Gateway service, we provide connectivity to various healthcare plans and states where Conduent EDI Solutions, Inc. is the fiscal agent, third-party administrator, or contracted clearinghouse. The Conduent State Healthcare Clearinghouse (SHCH) provides connectivity for the flow of medical information and data between medical providers, facilities, vendors, claim payment agencies, and other clearinghouses and the Front-end Online Transaction Processor (OLTP). Beyond the receipt and delivery of this data, Conduent SHCH provides translation to and from ANSI ASC X12N standard formats. The 837 transaction data will be submitted to the Conduent State Healthcare Clearinghouse (SHCH) for processing. Conduent SHCH validates submission of ANSI X12N format(s). If the file contains syntactical error(s), the segment(s) and elements(s) where the error(s) occurred will be reported in a 999 Functional Acknowledgement. The TA1 report is used to report receipt of individual interchange envelopes that contain corrupt data or an invalid trading partner relationship. The ANSI ASC X12N 835 can contain information related to payees, payers, dollar amount and payments. Audience This Companion Guide is intended for trading partner use in conjunction with the ANSI ASC X12N National Implementation Guide. The ANSI ASC X12N Implementation Guides can be accessed at This guide outlines the procedures necessary for engaging in Electronic Data Interchange (EDI) with Conduent EDI Solutions, Inc. and specifies data clarification where applicable. 5/6/2010 2

5 Chapter 2 Transmission Methods Conduent EDI Solutions provides an interactive, menu-driven bulletin board system that allows you to upload your transaction files and receive immediate confirmation of the status of your transfer. This Host Data Exchange system can be accessed using a standard modem and supports modem speeds of up to 56,000 BPS. Transaction transmission is available twenty-four hours a day, seven days a week. This availability is subject to scheduled and unscheduled host downtime. It is operational policy to schedule preventative maintenance periods on weekends whenever possible. Communication Protocols Conduent currently supports the following communication options: XMODEM, YMODEM, ZMODEM, Kermit Teleprocessing Requirements The general specifications for communication with Conduent are: Telecommunications Hayes-compatible K BPS asynchronous modem. File Format Compression Techniques ASCII text data. PKZIP will compress one or more files into a single ZIP archive. WINZIP will compress one or more files into a single ZIP archive. CONDUENT accepts transmission with any of the above compression techniques, as well as noncompression files. Data Format 8 data bit, 1stop bit, no parity, full duplex. 5/6/2010 3

6 Transmission Protocol ZMODEM uses 128 byte to 1024 byte variable packets and a 16-bit or 32-bit Cyclical Redundancy Check (CRC). XMODEM uses 128 byte blocks and a 16-bit CRC. YMODEM uses 1024 byte blocks and a 16-bit CRC. KERMIT can be accepted if X, Y, or ZMODEM capabilities are not available with your communication software. Teleprocessing Settings ASCII Sending Send line ends with line feeds (should not be set). Echo typed characters locally (should not be set). Line delay 0 milliseconds. Character delay 0 milliseconds. ASCII Receiving Append line feeds to incoming line ends should not be checked. Wrap lines that exceed terminal width. Terminal Emulation VT100 or Auto. 5/6/2010 4

7 Transmission Procedures SUBMITTER HOST SYSTEM 1. Dials Conduent Host Answers call, negotiates a common baud rate, and sends to the Trading Partner: Please enter your Login=> 2. Enters Login Name <CR> Receives User Name (Login Name) and sends to the Trading Partner: Please enter your password=> 3. Enters Password <CR> Receives Login and verifies if Trading Partner is an authorized user: Sends HOST selection menu followed by a user prompt: Please Select from the Menu Options Below=> 4. Enters Desired Selection <CR> #1. Electronic Claims Submission: Assigns and sends the transmission file name then waits for ZMODEM (by default) file transfer to be initiated by the Trading Partner. #2. View Submitter Profile #3. Select File Transfer Protocol: Allows you to change the protocol for the current submission only. The protocol may be changed to (k)ermit, (x)modem, (y)modem, or (z)modem. Enter selection [k,x,y,z]: #4. Download Confirmation #9. Exit & Disconnect: Terminates connection. 5/6/2010 5

8 5. Enters 1 to send file <CR> Receives ZMODEM (or other designated protocol) file transfer. Upon completion, initiates file confirmation. Sends file confirmation report. Sends HOST selection menu followed by a user prompt=> Please Select from the Menu Options Below=> 5/6/2010 6

9 Web Portal The web portal method allows a Trading Partner to initiate the submission of a batch file for processing. The Trading Partner must be an authenticated portal user who is a provider. The Trading Partner accesses the web portal via a web browser and is prompted for login and password. Files may be selected from their PC or work environment using the Browse function in conjunction with the add and remove functions. To transmit the selected files for processing, the Trading Partner must click the Submit link. All files submitted must be in the ANSI ASC X12N 837 format. Mainframe-to-Mainframe Connections Network Data Mover (NDM) and Network Data Mover (NDM) is a software product that transports data across a network. Trading partners wishing to utilize NDM must have a copy of the software and a mainframe with which to submit and receive their transactions. NDM is appropriate for submitters of very large transaction files, as it eliminates some of the transmission problems inherent in sending large files via asynchronous dial-up. Intermediaries and/or switch vendors primarily utilize this method of transmission. There are monthly connectivity and maintenance fees associated with this method of transmission. These fees are the responsibility of the external Trading Partner. Trading Partners wishing to establish an NDM connection must contact a Conduent EDI Support Unit Business Analyst, Monday through Friday from 8:00 a.m. to 5:00 p.m. EST at This service is available at a cost to the Trading Partners. 5/6/2010 7

10 Below is a summary of the tasks that must be completed by both the Trading Partner s IT Department and Conduent before transmission may begin. 1. NODE NAME NODE NAME must be defined by Programmer, Network Administrator, and Systems programmer who support VTAM / TCP/IP and CONNECT:DIRECT. 2. NETID NETID must be defined by Network Administrator and Systems Programmer who support VTAM / TCP/IP and CONNECT:DIRECT. 3. VTAM ID - TCP/IP Addr VTAM ID - TCP/IP Addr must be defined by Network Administrator and Systems Programmer who supports VTAM - TCP/IP and CONNECT:DIRECT. 4. ID and PASSWORD for Trading Partner Site Both the CONDUENT programmer and Trading Partner Security Administrator must create an ID and password. 5. ID and PASSWORD for CONDUENT The Trading Partner programmer and Conduent Security Administrator must create an ID and password. All batches submitted must be in the ANSI ASC X12N 837 format. 5/6/2010 8

11 Tape Cartridge Trading Partners may submit tape cartridges for processing although this is not the preferred method of submission. All tape cartridges submitted must be in the ANSI ASC X12N 837 format. Please use the instructions below for submitting tape cartridges to Conduent. 1. Please mail tape cartridges to: Conduent EDI Solutions Services, Inc. Production Control 2324 Killearn Center Blvd. Tallahassee, FL The following information must be affixed to the outside of the tape cartridge: Volume Serial Number: Transaction: Date Created: Provider Name: Provider Address: Production or Test: Record Length: Block Size: Dataset Name: 3. All tape cartridges must have a Department of Labor Tape Submission Form attached. Contact a Conduent EDI Business Analyst at to have a Tape Submission Form faxed to you. 5/6/2010 9

12 Chapter 3 Transmission Responses HIPAA not only gave the healthcare community the ability to standardize transactions, but also the ability to standardize front-end edits and the acceptance/rejection reports associated with the edits. The acceptance/rejection reports pertain to precision within EDI transaction format syntax and transaction implementation guide compliance. When a report is generated, the type of report returned is dependent on the edit level that is invalid. A transaction contains four levels where edits are present. The edit level in which the error occurs designates rejection of an entire batch or a single claim. The four levels are: Interchange Level Errors Functional Group Level Results Transaction Set Level Syntax Results Implementation Guide Level Results In the description below, the four levels and their affiliated acceptance/rejection reports are discussed. Interchange Level Errors and TA1 Rejection Report This edit is enforced by interchange level problems. These edits check the ISA, GS, GE and IEA level segments and the data content within these segments, which consist of the header and footer batch information. Any X12N syntax error that occurs at this level will result in the entire transaction being rejected. These rejections are reported on a TA1. TA1-Interchange Acknowledgement A TA1 is an ANSI ASC X12N Interchange Acknowledgement segment used to report receipt of individual interchange envelopes. An interchange envelope contains the sender, receiver, and data type information within the header. The TA1 reports the syntactical analysis of the interchange header and trailer. If invalid (e.g. the data is corrupt or the trading partner relationship does not exist within the CONDUENT system) the interchange will reject and a TA1, along with the data, will be forwarded to the Conduent EDI Solutions call center for referencing purposes. 5/6/

13 EXAMPLE: The transaction was built with incorrect sender information or incorrect total of groups at the end of the transaction: ISA (contains sender information) GS ST Detailed Segment Information-1 SE ST Detailed Segment Information-2 SE ST Detailed Segment Information-3 SE GE IEA (contains a number total of all functional groups within the batch) For an additional example of this report, please see the ANSI ASC X12N 837 Implementation Guide. Transaction Set Level Syntax Results and 999 Rejection Report This edit is enforced by transaction set level syntax problems for all transactions within each functional group. These edits check the ST and SE level segments and the data content within these segments. These segments consist of the entire detailed information within a transaction. Any X12N syntax error that occurs at this level will result in the entire transaction being rejected. However, if the functional group consists of additional transactions without errors, these will be processed. The rejections are reported on a /6/

14 999-Functional Acknowledgement Conduent SHCH validates submission of ANSI ASC X12N format(s). An ANSI ASC X12N 999, or Functional Acknowledgement, is generated when an EDI file, e.g. an ANSI ASC X12N file that has passed the header and trailer check, passes through the clearinghouse. The 999 contains ACCEPT or REJECT information; if the file contained syntactical errors, the segment(s) and element(s) where the error(s) occurred will be reported. For an example of this report, please see the ANSI ASC X12N 837 Implementation Guide. The Trading Partner Agreement between Conduent EDI Solutions and the Trading Partners requires this method of acknowledgement. EXAMPLE: The batch was built with incorrect segment data: ISA GS ST Detailed Segment Information-1 SE (contains detailed information within a transaction) ST Detailed Segment Information-2 SE (contains detailed information within a transaction) ST Detailed Segment Information-3 SE (contains detailed information within a transaction) GE IEA 5/6/

15 835-Remittance Advice An 835 Remittance Advice may be requested. After claim adjudication, an 835 Remittance Advice will be delivered to the Mailbox system. For further information, please see Chapter 4, Data Retrieval Methods. The ANSI ASC X12N 835 can contain information related to payees, payers, dollar amounts and payments. Please see the ANSI ASC X12N 835 Implementation Guide for details on the ANSI ASC X12N 835. Conduent Host Bulletin Board System The BBS allows Trading Partners to retrieve data via asynchronous dial-up. The trading partner will access the BBS using the login and password assigned to them during the EDI enrollment process. For more information regarding the Host System see Chapter 5 of the 835 guide. 5/6/

16 Chapter 4 Data Retrieval Methods Trading partners are only allowed to choose one method of retrieval per response and/or report. They are the Web Portal or the Conduent Host Bulletin Board. WEB PORTAL The web portal is the most efficient, and preferred means of data retrieval for Trading Partners with web access. The web portal provides a simple, secure message center (Intermediate Data Store (IDS)) for retrieval of response and/or reports to registered users. Trading Partners may enroll for the web portal via the web at www. Upon enrollment, users will receive a login and password for viewing or downloading their reports to their local workstation. Conduent HOST Bulletin Board System The BBS allows Trading Partners to retrieve data via asynchronous dialup. The trading partner will access the BBS using the login and password assigned to them during the EDI enrollment process. 5/6/

17 Chapter 5 Testing In order to expedite testing, we require providers to submit all X12 test transaction to EDIFECS prior to submitting them to Conduent EDI Solutions. EDIFECS service is free to providers to certify X12 readiness. A special EDIFECS services will verify Department of Labor specific edits, such as payer ID and claimant id. With these EDIFECS services you can test at any time and receive quick results making the process easier for everyone. For more information log onto Once certified by EDIFECS, submitter may submit test transactions to Conduent EDI Solutions. Completion of the testing process must occur prior to electronic submission to Conduent EDI Solutions. Assistance from Conduent EDI Support Unit Business Analysts is available throughout this process. Each test transmission is inspected thoroughly to ensure no format errors are present. Testing is conducted to verify the integrity of the format, not the integrity of the data; however, in order to simulate a production environment, we request that you send real transmission data. The number of test transmissions required depends on the number of format errors on a transmission and the relative severity of these errors. Additional testing may be required in the future to verify any changes made to Conduent s system. Also, changes to the ANSI formats may require additional testing. Trading Partner Testing Procedures 1. Conduent EDI Support Units make available companion guides and enrollment packages for download via the web. 2. Trading Partner completes enrollment package and submits to Conduent EDI Support Unit. 3. Trading Partner is assigned Logon Name and Logon User ID. 4. Trading Partner contacts Edifecs to test X12N formats. 5. Once cleared through EDIFECS, Trading Partner contacts the Conduent EDI Support Unit Business Analyst department to arrange a testing schedule. 6. Trading Partner executes test cases and data is sent to Conduent EDI Solutions. 7. Business Analyst evaluates flow of test data through the Conduent SHCH. 8. If test cases are completed successfully, the Business Analyst contacts the Trading Partner and the Trading Partner is approved for placement into production 5/6/

18 environment when available. If the testing entity is a software vendor, they will be required to provide a list of submitters using the approved software package. 9. If test cases are unsuccessful, the Business Analyst will contact the Trading Partner. The Trading Partner will remain in the testing environment until test cases are completed successfully. 5/6/

19 EDI Support Chapter 6 Payer Specific Data The Conduent EDI Support Unit assists users with questions about electronic submission. The Conduent EDI Support Unit is available to all Department of Labor clients and providers Monday through Friday from 8:00 a.m. to 8:00 p.m. EST at (800) The Conduent EDI Support Unit: Provides information on available services Enrolls users for claims submission Verifies receipt of electronic transmissions Provides technical assistance to users who are experiencing transmission difficulties Enrollment Information Any entity sending electronic claims to Conduent EDI Solutions for processing where reports and responses will be delivered must complete an EDI enrollment package. This package provides Conduent EDI Solutions the information necessary to assign a Logon Name, Logon ID, and Trading Partner ID, which are required to submit electronic claims. You may obtain an enrollment package by contacting the CONDUENT EDI Support Unit or by downloading it from our website at Transmission Telephone Number Conduent EDI Solutions provides availability for transmission 24 hours a day, 7 days a week. There are no restrictions on the number or frequency of transmissions. The transmission telephone numbers are (800) and (800) /6/

20 Tracking Transmission/Production Problems Highlights Please have the following information available when calling the Conduent EDI Support Unit regarding transmission and production issues. Trading Partner ID: Your Trading Partner ID is our key to accessing your Trading Partner information. Please have this number available each time you contact the Conduent EDI Support Unit. Logon Name and Logon User ID: These allow asynchronous Trading Partners access to the host system for claims submission. The Conduent EDI Support Unit uses this information to reference your submitted data. To promote efficient, accurate electronic transaction processing, please note: Each user is assigned a six-digit Trading Partner ID Login User IDs (passwords) are nine characters. All dates are in the CCYYMMDD format. All date/times are in the CCYYMMDDHHMM format. The same phone number will be used for transmitting test and production. Department of Labor Provider ID is nine characters long. Department of Labor Claimant ID is fifteen characters long. The Receiver ID/Payer ID for Department of Labor is Transmissions without this value in the appropriate fields will not be processed. The Trading Partner Enrollment Form determines where reports and responses will be delivered. 5/6/

21 Chapter 7 Transaction Description V5010.A1 This section contains data clarifications. The clarifications include: Identifiers to use when a national standard has not been adopted (and), Parameters in the implementation guide that provide options. Many of the data elements included in the Companion Guides are business requirements and are not standardization-required elements. Inclusion of a business-required data field, as defined by this Companion Guide, may aid in the delivery of a positive response. *Please note the page numbers listed below in each of the tables represent the corresponding page number in the ANSI ASC X12N Implementation Guide for this transaction Professional ENVELOPE HEADER. ENVELOPE INTERCHANGE CONTROL HEADER Appendix B.3 ISA R R ISA01 R R Value is 00. ISA02 R R Please use 10 spaces. ISA03 R R Value is 00. ISA04 R R Please use 10 spaces. ISA05 R R Value is ZZ. ISA06 R R Value is the 6-digit trading partner ID provided during the enrollment process. Please make sure this ID is left justified with trailing spaces to complete the 15-digit element. 05/06/10 18

22 ENVELOPE HEADER. ISA07 R R Value is ZZ. ISA08 R R ISA15 R R Value is Please make sure this element is left justified with trailing spaces to complete the 15-digit element. Value is T when submitting a test file. Value is P when submitting a production file. HEADER FUNCTIONAL GROUP HEADER Appendix B GS GS02 R R GS03 Please use the 6-digit trading partner ID provided during the enrollment process. Value is /06/10 19

23 TABLE 1: HEADER. 62 HEADER ST R R TRANSACTION SET HEADER 63 BHT R R R R 1000A 67 NM1 R R NM1 09 R R 76 PER R R 1000B Clarification When sending claims in pilot (test) mode, please use this value X098DA1. When sending claims in production mode, please use this value X098A1. SUBMITTER NAME Value is the 6-digit trading partner ID provided during the enrollment process. RECEIVER NAME 74 NM1 R R 75 NM1 03 R R Value is Department of Labor 75 NM1 09 R R Value is /6/

24 TABLE 2: DETAIL, BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL. 2000A 77 HL R R BILLING/PAY-TO-PROVIDER HIERARCHAL LEVEL PRV 2010AA BILLING PROVIDER NAME 84 NM1 R R 88 N3 R R 89 N4 R R 91 S R 01 R 02 R Clarification If the Billing Provider is the same entity as the Pay-to-Provider then the segment must be used to identify the Department of Labor provider number. The qualifier to be used for Department of Labor claim submissions is G2 Please use the Provider Commercial Number. PAY-TO PROVIDER NAME Clarification 2010AB 99 NM1 S S If the Pay-to-Provider is a different entity than the Billing Provider then the NM1, N3, N4, and segments of this loop are required for claim submissions. If not then do not use the 2010AB loop. NM101 R Value is 87. NM102 5/6/ R Value is 1 for a person, or value is 2 for an entity.

25 TABLE 2: DETAIL, BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL. NM103 R NM108 R NM109 R 102 N3 R R If NM102 is a person then enter the last name. If NM102 is and entity then enter the name of the organization. If NM103 is a person then the value is 34. If NM103 is an entity then value is 24. If NM104 is 34 then enter the Social Security Number. If NM104 is 24 then enter the Employer s Identification Number. 103 N4 R R 106 R R 01 R Value is G2 02 R Please use Provider Commercial Number. 5/6/

26 TABLE 2 DETAIL, SUBSCRIBER HIERARCHICAL LEVEL. 2000B 108 HL R R SUBSCRIBER HIERARCHAL LEVEL 110 SBR R R 2010BA SUBSCRIBER NAME 117 NM1 R R NM101 R R Value is IL. NM102 R R Value is 1. NM103 R R NM104 S R NM105 S S NM107 S S Value is the Subscriber last name. Value is the Subscriber first name. Value is the Subscriber middle initial if known. Value is the Subscriber name suffix if known. NM108 S R Value is MI. NM109 S R Please use 9- character alpha/numeric OWCP Case Number. 121 N3 S R 122 N4 S R 124 DMG S R 2010BB PAYER NAME 130 NM1 R R 5/6/

27 TABLE 2 DETAIL, SUBSCRIBER HIERARCHICAL LEVEL. 134 N3 S R 135 N4 S R 137 S R 2010BC Not Used 139 NM1 S RESPONSIBLE PARTY NAME 143 N3 S 144 N4 S 5/6/

28 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. USAG E 2000C Not Used PATIENT HIERARCHAL LEVEL 152 HL R 154 PAT S Clarification The patient is always the same as the subscriber for claims. 2010CA Not Used PATIENT NAME 2300 CLAIM INFORMATION 170 CLM R R 182 DTP S S 186 DTP S S 188 DTP S S 190 DTP S S 192 DTP S S 194 DTP S S 196 DTP S S 197 DTP S S 200 DTP S S 201 DTP S S 203 DTP S S 205 DTP S S 206 DTP S S 208 DTP S S 5/6/

29 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. USAG E 210 DTP S S 212 DTP S S 214 PWK S S 217 CN1 S S 219 AMT S R 220 AMT S R 221 AMT S R 222 S S 224 S S 226 S S 227 S S 229 S S 230 S S S S 233 S S 235 S S 236 S S 238 S S 240 S S 241 S S 242 S S 5/6/

30 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. USAG E 244 K3 S Not Used 246 NTE S S 248 CR1 S S 251 CR2 S S 257 CRC S S 260 CRC S S 263 CRC S Not Used 36 A1 CRC S S 265 HI S S 271 HCP S S 2310A ERRING PROVIDER NAME 282 NM1 S S 40 A1 PRV S S 288 S S 2310B S R Value is G R Please use the Provider Commercial Number. RENDERING PROVIDER NAME 290 NM1 S S 41 A1 PRV S S 296 S S 01 S R Value is G2 5/6/

31 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL 2310C. 02 USAG E 298 NM1 S S R Please use the Provider Commercial Number. PURCHASED SERVICE PROVIDER NAME 301 S S 2310D 01 R Value is G2 02 R Please use the Provider Commercial Number. SERVICE FACILITY LOCATION 303 NM1 S S 307 N3 R R 308 N4 R R 310 S S 2310E 312 NM1 S S SUPERVISING PROVIDER NAME 316 S S 2320 OTHER SUBSCRIBER INFORMATION 318 SBR S only allows one occurrence of this loop A SERVICE LINE LX R R SV1 R R Clarification The maximum is 39 service lines Clarification In SV101-1, for use value HC for HCPCS codes. Note that CPT codes are included in 5/6/

32 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. USAG E this coding structure A1 SV5 S S 410 PWK S S 412 CR1 S S 61 - A1 CR2 S Not used 421 CR3 S Not used 423 CR5 S S 427 CRC S S 430 CRC S S 432 CRC S S 64 - A1 DTP S S 437 DTP S S 440 DTP S S 442 DTP S S 64 - A1 DTP S S 65 - A1 DTP S S 449 DTP S S 451 DTP S S 452 DTP S S 454 DTP S S 456 DTP S S 66 - A1 DTP S S 5/6/

33 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. USAG E 460 DTP S S 67 - A1 MEA S S 466 CN1 S S 468 S S 469 S S 470 Prior Authorization or Referral Number S S Clarification Required if service line involved a prior authorization number or referral that is different than the number reported at the claim level (-ID-2300) 472 S S 69 - A1 S S 475 S S 477 S S 478 S S 479 S S 480 S S 482 S S 484 AMT S S 485 AMT S S 486 AMT S S 5/6/

34 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. USAG E 487 K3 S S 488 NTE S S 70 A1 PS1 S S 491 HSD S S 495 HCP S S 2410 DRUG IDENTIFICATION 71 - A1 LIN S S 74 - A1 CTP S S 77 - A1 S S 2420A RENDERING PROVIDER NAME 501 NM1 S S 79 - A1 PRV S S 507 S S 2420B 01 R Value is G2 02 R Please use the Provider Commercial Number. PURCHASED SERVICE PROVIDER 509 NM1 S S S S 2420C SERVICE FACILITY LOCATION 514 NM1 S S 5/6/

35 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. USAG E 518 N3 R R 519 N4 R R 521 S S 2420D SUPERVISING PROVIDER NAME 523 NM1 S S 527 S S 2420E 01 R Value is G2 02 R Please use the Provider Commercial Number. ORDERING PROVIDER NAME 529 NM1 S S 533 N3 S S 534 N4 S S 536 S S 538 PER S S 2420F ERRING PROVIDER NAME 541 NM1 S S 544 PRV S S 547 S S 2420G 01 R Value is G2 02 R Please use the Provider Commercial Number. OTHER PAYER PRIOR AUTHORIZATION OR 5/6/

36 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. USAG E ERRAL NUMBER 549 NM1 S S 552 R R Not Used Not Used 2430 LINE ADJUDICATION INFORMATION 554 SVD S S 558 CAS S S 566 DTP R R 2440 S S FORM IDENTIFICATION CODE 567 LQ S S 569 FRM R R 572 TRAILER SE TRANSACTION SET TRAILER 5/6/

37 ENVELOPE TRAILER SEGM ENT. Appendix B ENVELOPE GE R R FUNCTIONAL GROUP TRAILER Appendix B ENVELOPE IEA R R INTERCHANGE CONTROL TRAILER IEA02 R R Must be identical to ISA13. 5/6/

38 837- Dental ENVELOPE HEADER. Appendix B.3 ENVELOPE ISA R R INTERCHANGE CONTROL HEADER ISA01 R R Value is 00. ISA02 R R Please use 10 spaces. ISA03 R R Value is 00. ISA04 R R Please use 10 spaces. ISA05 R R Value is ZZ. ISA06 R R Value is the 6-digit trading partner ID provided during the enrollment process. Please make sure this ID is left justified with trailing spaces to complete the 15-digit element. ISA07 R R Value is ZZ. ISA08 R R Value is Please make sure this element is left justified with trailing spaces to complete the 15-digit element. Appendix B.8 HEADER GS ISA15 R R GS02 R R Value is T when submitting a test file. Value is P when submitting a production file. FUNCTIONAL GROUP HEADER Value is the 6-digit trading partner ID provided during the enrollment process. 5/6/

39 ENVELOPE HEADER. GS03 Value is TABLE 1: HEADER. 53 HEADER ST R R TRANSACTION SET HEADER 54 BHT R R R R 1000A 59 NM1 R R NM1 09 R R 63 PER R R 1000B Clarification When sending claims in pilot (test) mode, value is X097DA1. When sending claims in production mode, value is X097A1. SUBMITTER NAME Value is the 6-digit trading partner ID provided during the enrollment process RECEIVER NAME 66 NM1 R R 67 NM1 03 R R Value is Department of Labor 67 NM1 09 R R Value is /6/

40 TABLE 2: DETAIL, BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL. 2000A 69 HL R R BILLING/PAY-TO-PROVIDER HIERARCHAL LEVEL 71 PRV S S 2010AA BILLING PROVIDER NAME 76 NM1 R R 80 N3 R R 81 N4 R R 83 S R Clarification If the Billing Provider is the same entity as the Pay-to-Provider then the segment must be used to identify the provider number. 01 R Value is G2. 02 R Please use Provider Commercial Number. PAY-TO PROVIDER NAME 2010AB 87 NM1 S S Clarification If the Pay-to-Provider is a different entity than the Billing Provider then the NM1, N3, N4, and segments of this loop are required for claim submissions. If not then do not use the 2010AB loop. NM101 R Value is 87. NM102 NM103 5/6/ R R Value is 1 for a person, or value is 2 for an entity. If NM102 is a person then enter the last name.

41 TABLE 2: DETAIL, BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL. NM108 R NM109 R 91 N3 R R If NM102 is and entity then enter the name of the organization. If NM103 is a person then the value is 34. If NM103 is an entity then value is 24. If NM104 is 34 then enter the Social Security Number. If NM104 is 24 then enter the Employer s Identification Number. 92 N4 R R 94 R R 01 R Value is G2. 02 R Please use Provider Commercial Number. TABLE 2 DETAIL, SUBSCRIBER HIERARCHICAL LEVEL. 2000B 96 HL R R SUBSCRIBER HIERARCHAL LEVEL 99 SBR R R 2010BA SUBSCRIBER NAME 103 NM1 R R 5/6/

42 TABLE 2 DETAIL, SUBSCRIBER HIERARCHICAL LEVEL. NM101 R R Value is IL. NM102 R R Value is 1. NM103 R R NM104 S R NM105 S S NM107 S S Value is the Subscriber last name. Value is the Subscriber first name. Value is the Subscriber middle initial if known. Value is the Subscriber name suffix if known. NM1 08 S R Value is MI. NM1 09 S R 108 N3 S R 109 N4 S R 111 DMG S R Please use 9- character alpha/numeric OWCP Case Number. 2010BB PAYER NAME 117 NM1 R R 121 N3 S R 122 N4 S R 124 S R 2010BC 126 NM1 S NOT USED RESPONSIBLE PARTY NAME 5/6/

43 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. 2000C Not Used PATIENT HIERARCHAL LEVEL 132 HL S 134 PAT R Clarification The patient is always the same as the subscriber for claims. 2010CA Not Used PATIENT NAME 2300 CLAIM INFORMATION 149 CLM R R 157 DTP S S 158 DTP S S 160 DTP S S 161 DTP S S 162 DTP S S 164 DTP S S 166 DN1 S S 168 DN2 S S 170 PWK S S 173 AMT S S 174 AMT S Not Used 175 S Not used 16 A1 S S 179 S S S S 5/6/

44 181 S S 5/6/

45 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. 183 S S 185 NTE S S 2310A ERRING PROVIDER NAME 187 NM1 S S 190 PRV S S 193 S S 01 R R Value is G2 02 R R Please use Provider Commercial Number. 2310B RENDERING PROVIDER NAME 195 NM1 S S 19 A1 PRV S S 201 S S 01 R Value is G2 02 R Please use Provider Commercial Number. 2310C SERVICE FACILITY LOCATION 203 NM1 S S 207 S S 01 R Value is G2 02 R Please use Provider Commercial Number. 5/6/

46 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. 2310D ASSISTANT SURGEON NAME 20 A1 NM1 S S 23 A1 PRV S S 25 A1 S R S S Value is G2 02 S S Please use Provider Commercial Number. OTHER SUBSCRIBER INFORMATION 2330A R OTHER SUBSCRIBER NAME only allows one occurrence of this loop LINE COUNTER 265 LX R R 266 SV3 R R 271 TOO S S 32 A1 DTP S S 275 DTP S S 277 DTP S S 279 DTP S S 281 QTY S S 283 S S 33 A1 S S Clarification The maximum is 39 service lines 5/6/

47 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. 285 S S 287 AMT S S 34 A1 AMT S N/A 288 NTE S S 2420A 289 NM1 S S RENDERING PROVIDER NAME 35 A1 PRV S S 295 S S 01 R R Value is G2 02 R R Please use Provider Commercial Number. 2420B 297 NM1 S S OTHER PAYER PRIOR AUTHORIZATION OR ERRAL 36 A1 S S 2420C ASSISTANT SURGEON NAME 37 A1 NM1 S S 40 A1 PRV S S 42 A1 S S 01 R Value is G2 02 R Please use Provider Commercial Number. 5/6/

48 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL SVD S S LINE ADJUDICATION INFORMATION 305 CAS S S 312 DTP R R 313 TRANSACTION SET TRAILER 5/6/

49 ENVELOPE TRAILER SEGM ENT. ENVELOPE FUNCTIONAL GROUP TRAILER Appendix B GE R R ENVELOPE INTERCHANGE CONTROL TRAILER Appendix B IEA R R IEA02 R R Must be identical to ISA13. 5/6/

50 837- Institutional ENVELOPE HEADER SEGMEN T. USA GE ENVELOPE INTERCHANGE CONTROL HEADER Appendix B.3 ISA ISA01 R R Value is 00. ISA02 R R Please use 10 spaces. ISA03 R R Value is 00. ISA04 R R Please use 10 spaces. ISA05 R R Value is ZZ. ISA06 R R Value is the 6-digit trading partner ID provided during the enrollment process. Please make sure ID is left justified with trailing spaces to complete the 15-digit element. ISA07 R R Value is ZZ. ISA08 R R Value is Please make sure this element is left justified with trailing spaces to complete the 15-digit element. ISA15 R R Value is T when submitting a test file. Value is P when submitting a production file. Appendix B.8 ENVELOPE GS FUNCTIONAL GROUP HEADER GS02 R R Please use the 6-digit trading partner ID provided during the 5/6/

51 ENVELOPE HEADER SEGMEN T. USA GE enrollment process. GS03 Value is /6/

52 TABLE 1: HEADER. 56 ST R R 57 BHT R R R R 1000A 61 NM1 R R NM1 09 R R 64 PER R R 1000B Clarification When sending claims in pilot (test) mode, value is X096DA1. When sending claims in production mode, value is X096A1. SUBMITTER NAME Value is the 6-digit trading partner ID provided during the enrollment process. RECEIVER NAME 67 NM1 R R 68 NM1 03 R R Value is Department of Labor 68 NM1 09 R R Value is /6/

53 TABLE 2: DETAIL, BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL. 2000A 69 HL R R BILLING/PAY-TO-PROVIDER HIERARCHAL LEVEL 71 PRV S S 2010AA BILLING PROVIDER NAME 76 NM1 R R 79 N3 R R 80 N4 R R 82 S S Clarification If the Billing Provider is the same entity as the Pay-to-Provider then the segment must be used to identify the provider number. 82 RER 01 R Value is G R Please use Provider Commercial Number. 87 PER S S 2010AB 91 NM1 S S PAY-TO PROVIDER NAME Clarification If the Pay-to-Provider is a different entity than the Billing Provider then the NM1, N3, N4, and segments of this loop are required for claim submissions. If not then do not use the 2010AB loop. NM1 NM101 R Value is 87. 5/6/

54 TABLE 2: DETAIL, BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL. NM1 NM102 R NM1 NM103 R NM1 NM108 R NM1 NM109 R 94 N3 R R Value is 1 for a person, or value is 2 for an entity. If NM102 is a person then enter the last name. If NM102 is and entity then enter the name of the organization. If NM103 is a person then the value is 34. If NM103 is an entity then value is 24. If NM104 is 34 then enter the Social Security Number. If NM104 is 24 then enter the Employer s Identification Number. 95 N4 R R 97 R R R Value is G R Please use Provider Commercial Number. 5/6/

55 TABLE 2: DETAIL, SUBSCRIBER HIERARCHICAL LEVEL. 2000B 99 HL R R SUBSCRIBER HIERARCHAL LEVEL 101 SBR R R 2010BA SUBSCRIBER NAME 108 NM1 R R NM101 R R Value is IL. NM102 R R Value is 1. NM103 R R NM104 S R NM105 S S NM107 S S Value is the Subscriber last name. Value is the Subscriber first name. Value is the Subscriber middle initial if known. Value is the Subscriber name suffix if known. NM1 08 S R Value is MI. NM1 09 S R 112 N3 S R 113 N4 S R 115 DMG S R Please use 9- character alpha/numeric OWCP Case Number. 2010BC PAYER NAME 126 NM1 R R 129 N3 S S 5/6/

56 TABLE 2: DETAIL, SUBSCRIBER HIERARCHICAL LEVEL. 130 N4 S S 132 S S 2010BD S S RESPONSIBLE PARTY NAME 134 NM1 S S 136 N3 S S 137 N4 S S Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL C S Not Used PATIENT HIERCHICAL LEVEL HL R Clarification The patient is always the same as the subscriber for claims. 141 PAT R 2010CA Not Used PATIENT NAME 2300 CLAIM INFORMATION 157 CLM R R 5/6/

57 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. 165 DTP S S 167 DTP R R 169 DTP S S 171 CL1 S S 173 PWK S S 176 CN1 S S 178 AMT S S 180 AMT S S 182 AMT S S 184 AMT S S 185 S S 186 S S 187 S S 17 - A1 S S 191 S S S S 193 S S 195 S S 197 S S 198 S S 200 S S 5/6/

58 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. 202 S S 204 K3 S S 205 NTE S S 208 NTE S S 19 - A1 HI S S 230 HI S S 232 HI S S 242 HI S S 244 HI S S 256 HI S S 267 HI S S 280 HI S S 290 HI S S 299 HI S S 306 QTY S S 308 HCP S S 2310A 321 NM1 S S ATTENDING PHYSICIAN NAME PRV S S 326 S S R R Value is G2 5/6/

59 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL R R Please use Provider Commercial Number. 2310B 328 NM1 R R OPERATING PHYSICIAN NAME 333 S S R R Value is G R R Please use Provider Commercial Number. 2310C OTHER PROVIDER NAME 335 NM1 S S 340 S S R R Value is G R R Please use Provider Commercial Number. 2310D ERRING PROVIDER NM1 S S PRV S S S S 01 R R Value is G2 02 R R Please use Provider Commercial Number. 2310E SERVICE FACILITY NAME 5/6/

60 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. 349 NM1 S S 354 N3 R R 355 N4 R R 357 S S 01 R R Value is G2 02 R R Please use Provider Commercial Number OTHER SUBSCRIBER INFORMATION 359 SBR S only allows one occurrence of this loop SERVICE LINE NUMBER 444 LX R R 445 SV2 R R 452 PWK S S 26 - A1 DTP S S 28 A1 DTP S S 460 AMT S Not used 461 AMT S Not used Clarification The maximum is 59 service lines Clarification In SV102-1, for use value HC for HCPCS codes. Note that CPT codes are included in this coding structure A1 HCP S S 2410 S Not used DRUG IDENTIFICATION 5/6/

61 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL A1 LIN S S 38 - A1 CTP S S 40 - A1 S S 2420A 462 NM1 S S ATTENDING PHYSICIAN NAME 467 S S R R Value is G R R Please use Provider Commercial Number. 2420B 469 NM1 S S OPERATING PHYSICIAN NAME 474 S S R R Value is G R R Please use Provider Commercial Number. 2420C OTHER PROVIDER NAME 476 NM1 S S 481 S S R R Value is G R R Please use Provider Commercial Number SERVICE LINE ADJUDICATION 5/6/

62 Table 2 DETAIL, PATIENT HIERARCHICAL LEVEL. 490 SVD S S INFORMATION 494 CAS S S 502 DTP S S 503 SE R R TRANSACTION SET TRAILER ENVELOPE TRAILER SEGM ENT. ENVELOPE FUNCTIONAL GROUP Appendix B GE R R ENVELOPE INTERCHANGE CONTROL TRAILER Appendix B IEA R R IEA02 R R Must be identical to ISA13. 5/6/

63 Companion Guide Documentation Change Control Documentation change control is maintained in this document through the use of the Change Control Table shown below. All changes made to this companion guide after the creation date are noted along with the author, date, and reason for the change. Change Control Table Author of Change Page Change Reason Date M. Shields All Changes to reference CONDUENT EDI Support Unit in place of EDI Gateway Due to FA Support Unit Transition /1/2005 G. Roe All Change to reference CONDUENT,. Due to business merger February /06/2010 5/6/

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