text
stringlengths 332
10.9k
| source
stringclasses 42
values | doc_id
stringclasses 41
values | chunk_id
stringlengths 34
36
|
|---|---|---|---|
Separator 1 CAS11 Claim Adjustment Reason Code 1 5 Fourth claim adjustment reason code Element Separator 1 CAS12 Monetary Amount 1 18 Fourth claim adjustment amount Element Separator 1 Element Separator 1 135 CAS14 Claim Adjustment Reason Code 1 5 Fifth claim adjustment reason code Element Separator 1 CAS15 Monetary Amount 1 18 Fifth claim adjustment amount Element Separator 1 Element Separator 1 CAS17 Claim Adjustment Reason Code 1 5 Sixth claim adjustment reason code Element Separator 1 136 CAS18 Monetary Amount 1 18 Sixth claim adjustment amount Segment Terminator 1 Note: Additional CAS segments (up to 99 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 15 of 22 Page Loop ID Reference Name Codes Length Notes Comments total) will be mapped if there are more than six (6) EOB codes passed. 137 2100 NM1 Patient Name NM1 3 Individual or Organizational Name Element Separator 1 NM101 Entity Identifier Code QC Patient Name 2 Element Separator 1 138 NM102 Entity Type Qualifier 1 Person 1 Element Separator 1 NM103 Name, Last or Organization Name 1 60 Client Last Name Required for all claims that are not retail pharmacy claims. Required for retail pharmacy claims when the information is known. Element Separator 1 NM104 Name, First 1 35 Client First Name Required when the patient has a first name, and it is known. Element Separator 1 NM105 Name, Middle 1 25 Client Middle Name Element Separator 1 Element Separator 1 NM107 Name, Suffix 1 10 Client Name Suffix Element Separator 1 139 NM108 Identification Code Qualifier MI Member Identification Number 1 2 Element Separator 1 NM109 Identification Code 2 80 Client Medicaid ID Number Segment Terminator 1 146 2100 NM1 Service Provider Name NM1 3 Element Separator 1 147 NM101 Entity Identifier Code 82 Rendering Provider 2 3 Element Separator 1 NM102 Entity Type Qualifier 1 Person 2 Non-Person 1 Element Separator 1 NM103 Name, Last or Organization Name 1 60 Rendering Provider Last Name Element Separator 1 NM104 Name, First 1 35 Rendering Provider First Name Element Separator 1 148 Element Separator 1 Element Separator 1 Element Separator 1 NM108 Identification code Qualifier XX National Provider ID MC Medicaid Provider Number 1 2 Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 16 of 22 Page Loop ID Reference Name Codes Length Notes Comments 149 NM109 Identification Code 2 80 NPI or Provider ID Segment Terminator 1 Note: For TPL Claims: Information for up to three (3) Insurance Companies may be transmitted in N1 segments. If the insurance company name is not available, there will be no NM1 segments for the company. If both the company name and policyholder numbers are not available, neither NM1 segment will be mapped. 153 2100 NM1 Corrected Priority Payer Name NM1 3 Element Separator 1 NM101 Entity Identifier Code PR Payer 2 3 Element Separator 1 154 NM102 Entity Type Qualifier 2 Non-Person Entity 1 Element Separator 1 NM103 Name, Last or Organization Name 1 60 Corrected Priority Payer Name Element Separator 1 Element Separator 1 Element Separator 1 Element Separator 1 Element Separator 1 NM108 Identification code Qualifier PI Payer Identification 1 2 NM109 Identification Code 2 80 Payer Identification Number Segment Terminator 1 173 2100 DTM Statement From or To Date DTM 3 Claim Date Element Separator 1 174 DTM01 Date Time Qualifier 232 From Date of Service 233 To Date of Service 3 Element Separator 1 DTM02 Date CCYYMMDD 8 8 From Date of Service where DTM01 232 To Date of Service where DTM01 233 Segment Terminator 1 175 2100 DTM Coverage Expiration Date DTM 3 Element Separator 1 DTM01 Date Time Qualifier 036 Expiration 3 Element Separator 1 DTM02 Date CCYYMMDD 8 Segment Terminator 1 177 2100 DTM Claim Receive Date DTM 3 Element Separator 1 DTM01 Date Time Qualifier 050 - Received 3 Element Separator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 17 of 22 Page Loop ID Reference Name Codes Length Notes Comments DTM02 Date CCYYMMDD 8 Segment Terminator 1 184 2100 QTY Claim Supplemental Information Quantity QTY 3 Quantity Gainwell MS uses this segment; ID does not Element Separator 1 QTY01 Quantity Qualifier 2 Element Separator 1 185 QTY02 Quantity 1 15 Segment Terminator 1 186 2110 SVC Service Payment Information SVC 3 187 SVC01-1 Product Service ID Qualifier AD American Dental Association Codes HC HCFA HCPCS Codes N4 National Drug code 5-4-2 format 2 Component Separator: 1 188 SVC01-2 Product Service ID 1 48 Product Service Drug code Component Separator: 1 SVC01-3 Procedure Modifier 2 Modifier-1 Component Separator: 1 189 SVC01-4 Procedure Modifier 2 Modifier-2 Component Separator: 1 SVC01-5 Procedure Modifier 2 Modifier-3 Component Separator: 1 SVC01-6 Procedure Modifier 2 Modifier-4 Element Separator 1 SVC02 Monetary Amount 1 18 Total Charges Billed Element Separator 1 190 SVC03 Monetary Amount 1 18 Provider Payment Amount Element Separator 1 SVC04 Product Service ID 1 48 Revenue Code Element Separator 1 SVC05 Quantity 1 15 Paid Quantity Element Separator 1 Element Separator 1 193 SVC07 Quantity 1 15 Quantity Billed - if different from SVC05 Segment Terminator 1 194 2110 DTM Service Date DTM 3 2110 Element Separator 1 195 DTM01 Date Time Qualifier 150 Service Period Start 151 Service Period End 472 Service (for single-day service) 3 Element Separator 1 DTM02 Date CCYYMMDD 8 Service Date Segment Terminator 1 196 2110 CAS Service Adjustment CAS 3 see note 3 below Element Separator 1 198 CAS01 Claim Adjustment Group Code CO Contractual Obligations OA Other Adjustments 1 2 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 18 of 22 Page Loop ID Reference Name Codes Length Notes Comments PR Patient Responsibility Element Separator 1 CAS02 Claim Adjustment Reason Code 1 5 First claim adjustment reason code Element Separator 1 199 CAS03 Monetary Amount 1 18 First claim adjustment amount Element Separator 1 Element Separator 1 CAS05 Claim Adjustment Reason Code 1 5 Second claim adjustment reason code Element Separator 1 CAS06 Monetary Amount 1 18 Second claim | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide.pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_5 |
Reason Code 1 5 First claim adjustment reason code Element Separator 1 199 CAS03 Monetary Amount 1 18 First claim adjustment amount Element Separator 1 Element Separator 1 CAS05 Claim Adjustment Reason Code 1 5 Second claim adjustment reason code Element Separator 1 CAS06 Monetary Amount 1 18 Second claim adjustment amount Element Separator 1 200 Element Separator 1 CAS08 Claim Adjustment Reason Code 1 5 Third claim adjustment reason code Element Separator 1 CAS09 Monetary Amount 1 18 Third claim adjustment amount Element Separator 1 Element Separator 1 201 CAS11 Claim Adjustment Reason Code 1 5 Fourth claim adjustment reason code Element Separator 1 CAS12 Monetary Amount 1 18 Fourth claim adjustment amount Element Separator 1 Element Separator 1 202 CAS14 Claim Adjustment Reason Code 1 5 Fifth claim adjustment reason code Element Separator 1 CAS15 Monetary Amount 1 18 Fifth claim adjustment amount Element Separator 1 Element Separator 1 203 CAS17 Claim Adjustment Reason Code 1 5 Sixth claim adjustment reason code Element Separator 1 CAS18 Monetary Amount 1 18 Sixth claim adjustment amount Segment Terminator 1 Note: At a minimum, the Claim Detail CAS segment will contain the Claim Adjustment Group Code (CAS01), Claim Adjustment Code 1 (CAS02), and Adjustment Amount (CAS03). No other fields will be transmitted if there is no data. Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 19 of 22 Page Loop ID Reference Name Codes Length Notes Comments Note: A second CAS segment for the Claim Detail will be mapped if more than six (6) detail EOB codes are passed. 204 2110 REF Service Identification REF 3 Element Separator 1 REF01 Reference Identification Qualifier BB Authorization Number 2 3 Element Separator 1 205 REF02 Reference Identification 1 50 Trace Service Line Segment Terminator 1 206 2110 REF Line Item Control Number REF 3 Element Separator 1 REF01 Reference Identification Qualifier 6R Provider Control Number 2 3 Element Separator 1 REF02 Reference Identification 1 50 Line Item Control Number Segment Terminator 1 Note: Second REF segment for Rendering or Attending Provider Information exists and is populated with Medicaid Provider number only when the REF01 value in the previous REF segment is BB and its corresponding REF02 value is equal to a National Provider ID and when a Rendering or Attending Provider Number exists. 209 2110 REF Healthcare Policy Identification REF 3 Element Separator 1 210 REF01 Reference Identification Qualifier 0K Policy Form Identifying Number 2 3 Element Separator 1 REF02 Reference Identification 1 50 Healthcare Policy Identification Segment Terminator 1 211 2110 AMT Service Supplemental Amount AMT 3 Element Separator 1 AMT01 Amount Qualifier Code B6 Allowed Actual 1 3 Element Separator 1 212 AMT02 Monetary Amount 1 18 Amount Allowed Segment Terminator 1 215 2110 LQ Industry Code Health Care Remark Codes LQ 2 Element Separator 1 LQ01 Code List Qualifier Code HE Allowed Actual 1 3 Element Separator 1 216 LQ02 Industry Code 1 30 Remark Code Segment Terminator Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 20 of 22 Page Loop ID Reference Name Codes Length Notes Comments 217 Summ ary PLB Provider Adjustment PLB 3 Transaction Set Trailer Element Separator 1 218 PLB01 Reference Identification 1 50 Provider Number (If the Provider has an NPI, the NPI is used) Summ ary Element Separator 1 PLB02 Date CCYYMMDD 8 Last Day of Current Year Element Separator 1 219 PLB03-1 Adjustment Reason Code 2 Reason Code 1 Component Separator: 1 222 PLB03-2 Reference Identification 1 50 Reference Number 1 May be a Cash Control Number (CCN) or Internal Control Number (ICN) Element Separator 1 223 PLB04 Monetary Amount 1 18 Adjustment Amount 1 This field may also be NEGATIVE PAYMENT due to insufficient positive cash flow Element Separator 1 PLB05-1 Adjustment Reason Code 2 Reason Code 2 Component Separator: 1 PLB05-2 Reference Identification 1 50 Reference number 2 See Reference Number 1 Element Separator 1 224 PLB06 Monetary Amount 1 18 Adjustment Amount 2 See Adjustment Amount 1 Element Separator 1 PLB07-1 Adjustment Reason Code 2 Reason Code 3 Component Separator: 1 PLB07-2 Reference Identification 1 50 Reference number 3 See Reference Number 1 Element Separator 1 PLB08 Monetary Amount 1 18 Adjustment Amount 3 See Adjustment Amount 1 Element Separator 1 225 PLB09-1 Adjustment Reason Code 2 Reason Code 4 Component Separator: 1 PLB09-2 Reference Identification 1 50 Reference number 4 See Reference Number 1 Element Separator 1 PLB10 Monetary Amount 1 18 Adjustment Amount 4 See Adjustment Amount 1 Element Separator 1 PLB11-1 Adjustment Reason Code 2 Reason Code 5 Component Separator: 1 226 PLB11-2 Reference Identification 1 50 Reference number 5 See Reference Number 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 21 of 22 Page Loop ID Reference Name Codes Length Notes Comments Element Separator 1 PLB12 Monetary Amount 1 18 Adjustment Amount 5 See Adjustment Amount 1 Summ ary Element Separator 1 PLB13-1 Adjustment Reason Code 2 Reason Code 6 Component Separator: 1 PLB13-2 Reference Identification 1 50 Reference number 6 See Reference Number 1 Element Separator 1 227 PLB14 Monetary Amount 1 18 Adjustment Amount 6 See Adjustment Amount 1 Segment Terminator 1 228 TRAIL ER SE Transaction Set Trailer SE 2 3 Element Separator 1 SE01 Number of Included Segments 1 10 Total number of ST through SE segments Element Separator 1 SE02 Transaction Set Control Number 4 9 Assigned by Sender Must be identical to the value in ST02 Segment Terminator 1 C.9 GE Functional Group Trailer GE 2 Element Separator 1 GE01 Number of Transaction Sets Included 1 1 6 Element Separator 1 GE02 Group Control Number 1 9 Assigned by Sender Must be identical to the value in GS06 Segment Terminator 1 C.10 IEA Interchange Control Trailer IEA 3 Element Separator 1 IEA01 Number of Included Functional Groups 1 1 5 Element Separator 1 IEA02 Interchange Control Number 9 Assigned by Sender - Pad Left with Zeros Must be identical to value ISA13 Segment Terminator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide.pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_6 |
Separator 1 IEA01 Number of Included Functional Groups 1 1 5 Element Separator 1 IEA02 Interchange Control Number 9 Assigned by Sender - Pad Left with Zeros Must be identical to value ISA13 Segment Terminator 1 Idaho MMIS Companion Guide 835 Health Care Claim Payment Advice Last Updated: 02 29 2024 Page 22 of 22 Appendices Appendix A. Implementation Checklist The Trading Partner Account (TPA) User Guide contains information on how to select the correct trading partner entity type and answers some preliminary questions concerning trading partner registration. This guide can be found on the User Guides link under Reference Material on www.idmedicaid.com. | /kaggle/input/edi-db/CAQH 5010 835 Companion Guide.pdf | 69f62a9d267e4454bc0b0364e4df734f | 69f62a9d267e4454bc0b0364e4df734f_7 |
Stedi maintains this guide based on public documentation from CGS Medicare. Contact CGS Medicare for official EDI specifications. To report any errors in this guide, please contact us. X12 837 Health Care Claim: Institutional (X223A3) X12 Release 5010 Revised November 17, 2023 Go to Stedi Network This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Transaction Set (837) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to submit health care claim billing information, encounter information, or both, from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits is required or between payers and regulatory agencies to monitor the rendering, billing, and or payment of health care services within a specific health care insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies, and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance product or benefit or both. For example, a payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care insurance industry segment. Delimiters Segment Element Component Repetition 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 1 285 View the latest version of this implementation guide as an interactive webpage https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional- x223a3 01H25JDXFJR748R6M871MGNNCJ POWERED BY Build EDI implementation guides at stedi.com 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 2 285 Overview ISA - Interchange Control Header Max use 1 Required GS - Functional Group Header Max use 1 Required Heading ST 0050 Transaction Set Header Max use 1 Required BHT 0100 Beginning of Hierarchical Transaction Max use 1 Required Submitter Name Loop NM1 0200 Submitter Name Max use 1 Required PER 0450 Submitter EDI Contact Information Max use 2 Required Receiver Name Loop NM1 0200 Receiver Name Max use 1 Required Detail Billing Provider Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required PRV 0030 Billing Provider Specialty Information Max use 1 Optional Billing Provider Name Loop NM1 0150 Billing Provider Name Max use 1 Required N3 0250 Billing Provider Address Max use 1 Required N4 0300 Billing Provider City, State, ZIP Code Max use 1 Required REF 0350 Billing Provider Tax Identification Max use 1 Required PER 0400 Billing Provider Contact Information Max use 2 Optional Pay-to Address Name Loop NM1 0150 Pay-to Address Name Max use 1 Required N3 0250 Pay-to Address - ADDRESS Max use 1 Required N4 0300 Pay-To Address City, State, ZIP Code Max use 1 Required Subscriber Hierarchical Level Loop HL 0010 Hierarchical Level Max use 1 Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 3 285 SBR 0050 Subscriber Information Max use 1 Required Subscriber Name Loop NM1 0150 Subscriber Name Max use 1 Required N3 0250 Subscriber Address Max use 1 Optional N4 0300 Subscriber City, State, ZIP Code Max use 1 Optional DMG 0320 Subscriber Demographic Information Max use 1 Optional REF 0350 Property and Casualty Claim Number Max use 1 Optional Payer Name Loop NM1 0150 Payer Name Max use 1 Required N3 0250 Payer Address Max use 1 Optional N4 0300 Payer City, State, ZIP Code Max use 1 Optional REF 0350 Billing Provider Secondary Identification Max use 1 Optional Claim Information Loop CLM 1300 Claim Information Max use 1 Required DTP 1350 Admission Date Hour Max use 1 Optional DTP 1350 Date - Repricer Received Date Max use 1 Optional DTP 1350 Discharge Hour Max use 1 Optional DTP 1350 Statement Dates Max use 1 Required CL1 1400 Institutional Claim Code Max use 1 Required PWK 1550 Claim Supplemental Information Max use 10 Optional AMT 1750 Patient Estimated Amount Due Max use 1 Optional REF 1800 Adjusted Repriced Claim Number Max use 1 Optional REF 1800 Auto Accident State Max use 1 Optional REF 1800 Claim Identifier For Transmission Intermediaries Max use 1 Optional REF 1800 Demonstration Project Identifier Max use 1 Optional REF 1800 Investigational Device Exemption Number Max use 5 Optional REF 1800 Medical Record Number Max use 1 Optional REF 1800 Payer Claim Control Number Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 4 285 REF 1800 Peer Review Organization (PRO) Approval Number Max use 1 Optional REF 1800 Prior Authorization Max use 1 Optional REF 1800 Referral Number Max use 1 Optional REF 1800 Repriced Claim Number Max use 1 Optional REF 1800 Service Authorization Exception Code Max use 1 Optional K3 1850 File Information Max use 10 Optional NTE 1900 Billing Note Max use 1 Optional NTE 1900 Claim Note Max use 10 Optional CRC 2200 EPSDT Referral Max use 1 Optional HI 2310 Admitting Diagnosis Max use 1 Optional HI 2310 Condition Information Max use 2 Optional HI 2310 Diagnosis Related Group (DRG) Information Max use 1 Optional HI 2310 External Cause of Injury Max use 1 Optional HI 2310 Occurrence Information Max use 2 Optional HI 2310 Occurrence Span Information Max use 2 Optional HI 2310 Other Diagnosis Information Max use 2 | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_0 |
Max use 2 Optional HI 2310 Diagnosis Related Group (DRG) Information Max use 1 Optional HI 2310 External Cause of Injury Max use 1 Optional HI 2310 Occurrence Information Max use 2 Optional HI 2310 Occurrence Span Information Max use 2 Optional HI 2310 Other Diagnosis Information Max use 2 Optional HI 2310 Other Procedure Information Max use 2 Optional HI 2310 Patient's Reason For Visit Max use 1 Optional HI 2310 Principal Diagnosis Max use 1 Required HI 2310 Principal Procedure Information Max use 1 Optional HI 2310 Treatment Code Information Max use 2 Optional HI 2310 Value Information Max use 2 Optional HCP 2410 Claim Pricing Repricing Information Max use 1 Optional Attending Provider Name Loop NM1 2500 Attending Provider Name Max use 1 Required PRV 2550 Attending Provider Specialty Information Max use 1 Optional REF 2710 Attending Provider Secondary Identification Max use 4 Optional Operating Physician Name Loop 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 5 285 NM1 2500 Operating Physician Name Max use 1 Required REF 2710 Operating Physician Secondary Identification Max use 4 Optional Other Operating Physician Name Loop NM1 2500 Other Operating Physician Name Max use 1 Required REF 2710 Other Operating Physician Secondary Identification Max use 4 Optional Rendering Provider Name Loop NM1 2500 Rendering Provider Name Max use 1 Required REF 2710 Rendering Provider Secondary Identification Max use 4 Optional Service Facility Location Name Loop NM1 2500 Service Facility Location Name Max use 1 Required N3 2650 Service Facility Location Address Max use 1 Required N4 2700 Service Facility Location City, State, ZIP Code Max use 1 Required REF 2710 Service Facility Location Secondary Identification Max use 3 Optional Referring Provider Name Loop NM1 2500 Referring Provider Name Max use 1 Required Other Subscriber Information Loop SBR 2900 Other Subscriber Information Max use 1 Required CAS 2950 Claim Level Adjustments Max use 5 Optional AMT 3000 Coordination of Benefits (COB) Payer Paid Amount Max use 1 Optional AMT 3000 Coordination of Benefits (COB) Total Non- Covered Amount Max use 1 Optional AMT 3000 Remaining Patient Liability Max use 1 Optional OI 3100 Other Insurance Coverage Information Max use 1 Required MIA 3150 Inpatient Adjudication Information Max use 1 Optional MOA 3200 Outpatient Adjudication Information Max use 1 Optional Other Subscriber Name Loop NM1 3250 Other Subscriber Name Max use 1 Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 6 285 N3 3320 Other Subscriber Address Max use 1 Optional N4 3400 Other Subscriber City, State, ZIP Code Max use 1 Optional REF 3550 Other Subscriber Secondary Identification Max use 2 Optional Other Payer Name Loop NM1 3250 Other Payer Name Max use 1 Required N3 3320 Other Payer Address Max use 1 Optional N4 3400 Other Payer City, State, ZIP Code Max use 1 Optional DTP 3500 Claim Check or Remittance Date Max use 1 Optional REF 3550 Other Payer Claim Adjustment Indicator Max use 1 Optional REF 3550 Other Payer Claim Control Number Max use 1 Optional REF 3550 Other Payer Prior Authorization Number Max use 1 Optional REF 3550 Other Payer Referral Number Max use 1 Optional REF 3550 Other Payer Secondary Identifier Max use 2 Optional Service Line Number Loop LX 3650 Service Line Number Max use 1 Required SV2 3750 Institutional Service Line Max use 1 Required PWK 4200 Line Supplemental Information Max use 10 Optional DTP 4550 Date - Service Date Max use 1 Optional REF 4700 Adjusted Repriced Line Item Reference Number Max use 1 Optional REF 4700 Line Item Control Number Max use 1 Optional REF 4700 Repriced Line Item Reference Number Max use 1 Optional AMT 4750 Facility Tax Amount Max use 1 Optional AMT 4750 Service Tax Amount Max use 1 Optional NTE 4850 Third Party Organization Notes Max use 1 Optional HCP 4920 Line Pricing Repricing Information Max use 1 Optional Drug Identification Loop LIN 4930 Drug Identification Max use 1 Required CTP 4940 Drug Quantity Max use 1 Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 7 285 REF 4950 Prescription or Compound Drug Association Number Max use 1 Optional Operating Physician Name Loop NM1 5000 Operating Physician Name Max use 1 Required REF 5250 Operating Physician Secondary Identification Max use 20 Optional Other Operating Physician Name Loop NM1 5000 Other Operating Physician Name Max use 1 Required REF 5250 Other Operating Physician Secondary Identification Max use 20 Optional Rendering Provider Name Loop NM1 5000 Rendering Provider Name Max use 1 Required REF 5250 Rendering Provider Secondary Identification Max use 20 Optional Referring Provider Name Loop NM1 5000 Referring Provider Name Max use 1 Required REF 5250 Referring Provider Secondary Identification Max use 20 Optional Line Adjudication Information Loop SVD 5400 Line Adjudication Information Max use 1 Required CAS 5450 Line Adjustment Max use 5 Optional DTP 5500 Line Check or Remittance Date Max use 1 Required AMT 5505 Remaining Patient Liability Max use 1 Optional SE 5550 Transaction Set Trailer Max use 1 Required GE - Functional Group Trailer Max use 1 Required IEA - Interchange Control Trailer Max use 1 Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 8 285 ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange- related control segments Example ISA 00 00 XX XXXXXXXXXXXXXX X XX XXXXXXXXXXXXXXX 250131 0655 00501 00000000 0 X X Max use 1 Required ISA-01 I01 Authorization Information Qualifier Identifier (ID) Required Code identifying the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_1 |
the type of information in the Authorization Information 00 No Authorization Information Present (No Meaningful Information in I02) ISA-02 I02 Authorization Information Min 10 Max 10 String (AN) Required Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01) ISA-03 I03 Security Information Qualifier Identifier (ID) Required Code identifying the type of information in the Security Information 00 No Security Information Present (No Meaningful Information in I04) ISA-04 I04 Security Information Min 10 Max 10 String (AN) Required This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03) ISA-05 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-06 I06 Interchange Sender ID Min 15 Max 15 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 9 285 Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element ISA-07 I05 Interchange ID Qualifier Min 2 Max 2 Identifier (ID) Required Code indicating the system method of code structure used to designate the sender or receiver ID element being qualified Codes ISA-08 I07 Interchange Receiver ID Min 15 Max 15 String (AN) Required Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them ISA-09 I08 Interchange Date YYMMDD format Date (DT) Required Date of the interchange ISA-10 I09 Interchange Time HHMM format Time (TM) Required Time of the interchange ISA-11 I65 Repetition Separator Min 1 Max 1 String (AN) Required Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator Repetition Separator ISA-12 I11 Interchange Control Version Number Identifier (ID) Required Code specifying the version number of the interchange control segments 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003 ISA-13 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender ISA-14 I13 Acknowledgment Requested Min 1 Max 1 Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 10 285 Code indicating sender's request for an interchange acknowledgment 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1) ISA-15 I14 Interchange Usage Indicator Min 1 Max 1 Identifier (ID) Required Code indicating whether data enclosed by this interchange envelope is test, production or information I Information P Production Data T Test Data ISA-16 I15 Component Element Separator Min 1 Max 1 String (AN) Required Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator Component Element Separator 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 11 285 GS Functional Group Header To indicate the beginning of a functional group and to provide control information Example GS HC XXX XXXXXXX 20250130 2128 0000000 X 005010X 223A3 Max use 1 Required GS-01 479 Functional Identifier Code Identifier (ID) Required Code identifying a group of application related transaction sets HC Health Care Claim (837) GS-02 142 Application Sender's Code Min 2 Max 15 String (AN) Required Code identifying party sending transmission; codes agreed to by trading partners GS-03 124 Application Receiver's Code Min 2 Max 15 String (AN) Required Code identifying party receiving transmission; codes agreed to by trading partners GS-04 373 Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year GS-05 337 Time HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time (TM) Required Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) GS-06 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender GS-07 455 Responsible Agency Code Min 1 Max 2 Identifier (ID) Required Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 12 285 T Transportation Data Coordinating Committee (TDCC) X Accredited Standards Committee X12 GS-08 480 Version Release Industry Identifier Code String (AN) Required Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed 005010X223A3 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 13 285 Heading ST 0050 Heading ST Transaction Set Header | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_2 |
if code in DE455 in GS segment is T, then other formats are allowed 005010X223A3 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 13 285 Heading ST 0050 Heading ST Transaction Set Header To indicate the start of a transaction set and to assign a control number Example ST 837 0001 005010X223A3 Max use 1 Required ST-01 143 Transaction Set Identifier Code Identifier (ID) Required Code uniquely identifying a Transaction Set The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set). 837 Health Care Claim ST-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. ST-03 1705 Version, Release, or Industry Identifier String (AN) Required Reference assigned to identify Implementation Convention The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08. Usage notes This element must be populated with the guide identifier named in Section 1.2. This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is used at translation time. 005010X223A3 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 14 285 BHT 0100 Heading BHT Beginning of Hierarchical Transaction To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time Usage notes The second example denotes the case where the entire transaction set contains ENCOUNTERS. Example BHT 0019 00 XXX 20250130 2237 CH Max use 1 Required BHT-01 1005 Hierarchical Structure Code Identifier (ID) Required Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set 0019 Information Source, Subscriber, Dependent BHT-02 353 Transaction Set Purpose Code Identifier (ID) Required Code identifying purpose of transaction set Usage notes BHT02 is intended to convey the electronic transmission status of the 837 batch contained in this ST-SE envelope. The terms "original" and "reissue" refer to the electronic transmission status of the 837 batch, not the billing status. 00 Original Original transmissions are transmissions which have never been sent to the receiver. BHT-03 127 Originator Application Transaction Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system. Usage notes The inventory file number of the transmission assigned by the submitter's system. This number operates as a batch control number. This field is limited to 30 characters. BHT-04 373 Transaction Set Creation Date CCYYMMDD format Date (DT) Required Date expressed as CCYYMMDD where CC represents the first two digits of the calendar 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 15 285 year BHT04 is the date the transaction was created within the business application system. Usage notes This is the date that the original submitter created the claim file from their business application system. BHT-05 337 Transaction Set Creation Time Time (TM) Required HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H hours (00-23), M minutes (00-59), S integer seconds (00-59) and DD decimal seconds; decimal seconds are expressed as follows: D tenths (0-9) and DD hundredths (00-99) BHT05 is the time the transaction was created within the business application system. Usage notes This is the time that the original submitter created the claim file from their business application system. BHT-06 640 Claim Identifier Identifier (ID) Required Code specifying the type of transaction CH Chargeable Use CH when the transaction contains only fee for service claims or claims with at least one chargeable line item. If it is not clear whether a transaction contains claims or capitated encounters, or if the transaction contains a mix of claims and capitated encounters, use CH. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 16 285 1000A Submitter Name Loop Max 1 Required Variants (all may be used) Receiver Name Loop NM1 0200 Heading Submitter Name Loop NM1 Submitter Name To supply the full name of an individual or organizational entity Usage notes The submitter is the entity responsible for the creation and formatting of this transaction. Example NM1 41 2 X X XXXX 46 XXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 41 Submitter NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Submitter Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Submitter First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Submitter Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_3 |
Optional Individual first name NM1-05 1037 Submitter Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 17 285 Medicare does not support the submission of foreign currency. NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) Established by trading partner agreement NM1-09 67 Submitter Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes The MAC will reject an interchange (transmission) that is submitted with a submitter identification number that is not authorized for electronic claim submission. Submitter ID must match the value submitted in ISA06 and GS02. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 18 285 PER 0450 Heading Submitter Name Loop PER Submitter EDI Contact Information To identify a person or office to whom administrative communications should be directed Usage notes When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". The contact information in this segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization. There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PER IC XXXXX EM XXXX EM X FX X If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Required PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Submitter Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 19 285 1000A Submitter Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 20 285 1000B Receiver Name Loop Max 1 Required Variants (all may be used) Submitter Name Loop NM1 0200 Heading Receiver Name Loop NM1 Receiver Name To supply the full name of an individual or organizational entity Example NM1 40 2 XXX 46 XX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 40 Receiver NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Receiver Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) 46 Electronic Transmitter Identification Number (ETIN) NM1-09 67 Receiver Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 21 285 1000B Receiver Name Loop end Heading end The MAC will reject an interchange (transmission) that is not submitted with a valid Part A MAC code. Each individual MAC determines this identifier. Submitter ID must match the value submitted in ISA08 and GS03. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 22 285 Detail 2000A Billing Provider Hierarchical Level Loop Max 1 Required HL 0010 Detail Billing Provider Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 1 20 1 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_4 |
segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 20 Information Source HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 Additional Subordinate HL Data Segment in This Hierarchical Structure. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 23 285 PRV 0030 Detail Billing Provider Hierarchical Level Loop PRV Billing Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when the payer's adjudication is known to be impacted by the provider taxonomy code. If not required by this implementation guide, do not send. Example PRV BI PXC XX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider BI Billing PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 24 285 2010AA Billing Provider Name Loop Max 1 Required Variants (all may be used) Pay-to Address Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop NM1 Billing Provider Name To supply the full name of an individual or organizational entity Usage notes Beginning on the NPI compliance date: When the Billing Provider is an organization health care provider, the organization health care provider's NPI or its subpart's NPI is reported in NM109. When a health care provider organization has determined that it needs to enumerate its subparts, it will report the NPI of a subpart as the Billing Provider. The subpart reported as the Billing Provider MUST always represent the most detailed level of enumeration as determined by the organization health care provider and MUST be the same identifier sent to any trading partner. For additional explanation, see section 1.10.3 Organization Health Care Provider Subpart Presentation. Prior to the NPI compliance date, proprietary identifiers necessary for the receiver to identify the Billing Provider entity are to be reported in the REF segment of Loop ID- 2010BB. The Taxpayer Identifying Number (TIN) of the Billing Provider to be used for 1099 purposes must be reported in the REF segment of this loop. When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop. Example NM1 85 2 XXXX XX XXXXX If either Identification Code Qualifier (NM1-08) or Billing Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 85 Billing Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 25 285 NM1-03 1035 Billing Provider Organizational Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Billing Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 26 285 N3 0250 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop N3 Billing Provider Address To specify the location of the named party Usage notes The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary. Example N3 X XXXX Max use 1 Required N3-01 166 Billing Provider Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Billing Provider Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 27 285 N4 0300 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop N4 Billing Provider City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXX XX XXX XX Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_5 |
01H25JDXFJR748R6M871MGNNCJ 27 285 N4 0300 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop N4 Billing Provider City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXX XX XXX XX Only one of Billing Provider State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Billing Provider City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Billing Provider State or Province Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Billing Provider Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 28 285 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 29 285 REF 0350 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop REF Billing Provider Tax Identification To specify identifying information Usage notes This is the tax identification number (TIN) of the entity to be paid for the submitted services. Example REF EI X Max use 1 Required REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. REF-02 127 Billing Provider Tax Identification Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 30 285 PER 0400 Detail Billing Provider Hierarchical Level Loop Billing Provider Name Loop PER Billing Provider Contact Information To identify a person or office to whom administrative communications should be directed Usage notes Required when this information is different than that contained in the Loop ID-1000A - Submitter PER segment. If not required by this implementation guide, do not send.; When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number must always include the area code and phone number using the format AAABBBCCCC where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as "1", in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension. Do not include data that indicates an extension, such as "ext" or "x-". There are 2 repetitions of the PER segment to allow for six possible combinations of communication numbers including extensions. Example PER IC XXX FX XXXXXX FX X EM XXXX If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required Max use 2 Optional PER-01 366 Contact Function Code Identifier (ID) Required Code identifying the major duty or responsibility of the person or group named IC Information Contact PER-02 93 Billing Provider Contact Name Min 1 Max 60 String (AN) Optional Free-form name PER-03 365 Communication Number Qualifier Identifier (ID) Required Code identifying the type of communication number EM Electronic Mail FX Facsimile TE Telephone PER-04 364 Communication Number Min 1 Max 256 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 31 285 2010AA Billing Provider Name Loop end Complete communications number including country or area code when applicable PER-05 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-06 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable PER-07 365 Communication Number Qualifier Identifier (ID) Optional Code identifying the type of communication number EM Electronic Mail EX Telephone Extension FX Facsimile TE Telephone PER-08 364 Communication Number Min 1 Max 256 String (AN) Optional Complete communications number including country or area code when applicable 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 32 285 2010AB Pay-to Address Name Loop Max 1 Optional Variants (all may be used) Billing Provider Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop NM1 Pay-to Address Name To supply the full name of an individual or organizational entity Usage notes Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.; The purpose of Loop ID-2010AB has changed from previous | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_6 |
NM1 Pay-to Address Name To supply the full name of an individual or organizational entity Usage notes Required when the address for payment is different than that of the Billing Provider. If not required by this implementation guide, do not send.; The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address. There are no applicable identifiers for Pay-To Address information. Example NM1 87 2 Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 87 Pay-to Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 33 285 N3 0250 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop N3 Pay-to Address - ADDRESS To specify the location of the named party Example N3 XXXXXX XXXXXX Max use 1 Required N3-01 166 Pay-To Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Pay-To Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 34 285 N4 0300 Detail Billing Provider Hierarchical Level Loop Pay-to Address Name Loop N4 Pay-To Address City, State, ZIP Code To specify the geographic place of the named party Example N4 XXXX XX XXXXXX XX Only one of Pay-to Address State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Pay-to Address City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Pay-to Address State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Pay-to Address Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 35 285 2010AB Pay-to Address Name Loop end 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 36 285 2000B Subscriber Hierarchical Level Loop Max 1 Required HL 0010 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop HL Hierarchical Level To identify dependencies among and the content of hierarchically related groups of data segments Example HL 2 1 22 0 Max use 1 Required HL-01 628 Hierarchical ID Number Min 1 Max 12 String (AN) Required A unique number assigned by the sender to identify a particular data segment in a hierarchical structure HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction. HL-02 734 Hierarchical Parent ID Number Min 1 Max 12 String (AN) Required Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate. HL-03 735 Hierarchical Level Code Identifier (ID) Required Code defining the characteristic of a level in a hierarchical structure HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information. 22 Subscriber HL-04 736 Hierarchical Child Code Identifier (ID) Optional Code indicating if there are hierarchical child data segments subordinate to the level being described HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 37 285 0 No Subordinate HL Segment in This Hierarchical Structure. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 38 285 SBR 0050 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop SBR Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Example SBR P 18 XXXXXX XXX OF Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. P Primary S Secondary T Tertiary SBR-02 1069 Individual Relationship Code Identifier (ID) Optional Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. Usage notes For Medicare, the subscriber is always | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_7 |
Code (other than value "U") may occur no more than once. P Primary S Secondary T Tertiary SBR-02 1069 Individual Relationship Code Identifier (ID) Optional Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. Usage notes For Medicare, the subscriber is always the same as the patient. 18 Self SBR-03 127 Subscriber Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop ID-2010BA-NM109. SBR-04 93 Subscriber Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 39 285 Code identifying type of claim Usage notes For Medicare, the subscriber is always the same as the patient. 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MA Medicare Part A MB Medicare Part B MC Medicaid OF Other Federal Program Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 40 285 2010BA Subscriber Name Loop Max 1 Required Variants (all may be used) Payer Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop NM1 Subscriber Name To supply the full name of an individual or organizational entity Usage notes In worker's compensation or other property and casualty claims, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state. Example NM1 IL 1 XXXXXX XXX X XX MI XXXXX If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Subscriber Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Subscriber First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Subscriber Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 41 285 The first position must be alphabetic (A-Z). NM1-07 1039 Subscriber Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name Usage notes Examples: I, II, III, IV, Jr, Sr This data element is used only to indicate generation or patronymic. NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service Contract Health Services (IHS CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Subscriber Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes The MBI: must be 11 positions in the format of C A AN N A AN N A A N N where C represents a constrained numeric 1 thru 9, A represents alphabetic character A Z but excluding S, L, O, I, B, Z, N represents numeric 0 thru 9, and AN represents either A or N. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 42 285 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop N3 Subscriber Address To specify the location of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N3 XXXXXX XXXXXX Max use 1 Optional N3-01 166 Subscriber Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Subscriber Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 43 285 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop N4 Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N4 XXXX XX XXXXXXXX XXX Only one of Subscriber State Code (N4-02) or Country | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_8 |
Code To specify the geographic place of the named party Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example N4 XXXX XX XXXXXXXX XXX Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Subscriber City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Subscriber State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Subscriber Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 44 285 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 45 285 DMG 0320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop DMG Subscriber Demographic Information To supply demographic information Usage notes Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send. Example DMG D8 X F Max use 1 Optional DMG-01 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format D8 Date Expressed in Format CCYYMMDD DMG-02 1251 Subscriber Birth Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth. Usage notes Must not be a future date. DMG-03 1068 Subscriber Gender Code Identifier (ID) Required Code indicating the sex of the individual F Female M Male U Unknown 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 46 285 2010BA Subscriber Name Loop end REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Subscriber Name Loop REF Property and Casualty Claim Number To specify identifying information Usage notes This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.; This segment is not a HIPAA requirement as of this writing. Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. Example REF Y4 XXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Y4 Agency Claim Number REF-02 127 Property Casualty Claim Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 47 285 2010BB Payer Name Loop Max 1 Required Variants (all may be used) Subscriber Name Loop NM1 0150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop NM1 Payer Name To supply the full name of an individual or organizational entity Usage notes This is the destination payer. For the purposes of this implementation the term payer is synonymous with several other terms, such as, repricer and third party administrator. Example NM1 PR 2 X PI XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Payer Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 48 285 Identification, that would have been sent using qualifier PI, in the corresponding REF segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification NM1-09 67 Payer Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 49 285 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N3 Payer Address | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_9 |
a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 49 285 N3 0250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N3 Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3 XXXX XXXXXX Max use 1 Optional N3-01 166 Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 50 285 N4 0300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop N4 Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4 XX XX XXXXX XX Only one of Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 51 285 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 52 285 2010BB Payer Name Loop end REF 0350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Payer Name Loop REF Billing Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated NPI Implementation Date when an additional identification number is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in Loop 2010AA is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF LU XXXXX Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Billing Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 53 285 2300 Claim Information Loop Max 100 Optional CLM 1300 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CLM Claim Information To specify basic data about the claim Usage notes The developers of this implementation guide recommend that trading partners limit the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. There is no recommended limit to the number of ST-SE transactions within a GS-GE or ISA- IEA. Willing trading partners can agree to set limits higher. For purposes of this documentation, the claim detail information is presented only in the dependent level. Specific claim detail information can be given in either the subscriber or the dependent hierarchical level. Because of this, the claim information is said to "float." Claim information is positioned in the same hierarchical level that describes its owner-participant, either the subscriber or the dependent. In other words, the claim information, Loop ID-2300, is placed following Loop ID-2010BB in the Subscriber Hierarchical Level (HL) when patient information is sent in Loop ID-2010BA of the Subscriber HL. Claim information is placed in the Patient HL when the patient information is sent in Loop ID-2010CA of the Patient HL. When the patient is the subscriber or is considered to be the subscriber, Loop ID-2000C and Loop ID-2010CA are not sent. See Subscriber Patient HL Segment explanation in section 1.4.3.2.2.1 for details. Example CLM XXX 0000 X A X A Y Y 4 Max use 1 Required CLM-01 1028 Patient Control Number Min 1 Max 38 String (AN) Required Identifier used to track a claim from creation by the health care provider through payment Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_10 |
Usage notes The number that the submitter transmits in this position is echoed back to the submitter in the 835 and other transactions. This permits the submitter to use the value in this field as a key in the submitter's system to match the claim to the payment information returned in the 835 transaction. The two recommended identifiers are either the Patient Account Number or the Claim Number in the billing submitter's patient management system. The developers of this implementation guide strongly recommend that submitters use unique numbers for this field for each individual claim. When Loop ID-2010AC is present, CLM01 represents the subrogated Medicaid agency's claim number (ICN DCN) from their original 835 CLP07 - Payer Claim Control Number. See Section 1.4.1.4 of the front matter for a description of post payment recovery claims for subrogated Medicaid agencies. The maximum number of characters to be supported for this field is 20'. Characters beyond the maximum are not required to be stored nor returned by any 837-receiving system. CLM-02 782 Total Claim Charge Amount Min 1 Max 15 Decimal number (R) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 54 285 Monetary amount CLM02 is the total amount of all submitted charges of service segments for this claim. Usage notes The Total Claim Charge Amount must be greater than or equal to zero. The total claim charge amount must balance to the sum of all service line charge amounts reported in the Institutional Service Line (SV2) segments for this claim. When Medicare is primary payer, CLM02 must equal the sum of all SV203 service line charge amounts. When Medicare is Secondary or Tertiary payer, Total Submitted Charges (CLM02) must equal the sum of all 2320 2430 CAS amounts and the 2320 AMT02 (AMT01 D ). CLM-05 C023 Health Care Service Location Information To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Max use 1 Required C023-01 1331 Facility Type Code Min 1 Max 2 String (AN) Required Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services. C023-02 1332 Facility Code Qualifier Identifier (ID) Required Code identifying the type of facility referenced C023-02 qualifies C023-01 and C023-03. A Uniform Billing Claim Form Bill Type C023-03 1325 Claim Frequency Code Min 1 Max 1 Identifier (ID) Required Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type CLM-07 1359 Assignment or Plan Participation Code Identifier (ID) Required Code indicating whether the provider accepts assignment Usage notes Within this element the context of the word assignment is related to the relationship between the provider and the payer. This is NOT the field for reporting whether the patient has or has not assigned benefits to the provider. The benefit assignment indicator is in CLM08. A Assigned Required when the provider accepts assignment and or has a participation agreement with the destination payer. OR 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 55 285 Required when the provider does not accept assignment and or have a participation agreement, but is advising the payer to adjudicate this specific claim under participating provider benefits as allowed under certain plans. B Assignment Accepted on Clinical Lab Services Only Required when the provider accepts assignment for Clinical Lab Services only. C Not Assigned Required when neither codes A' nor B' apply. CLM-08 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CLM08 is 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. Usage notes This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes CLM-09 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. CLM-20 1514 Delay Reason Code Identifier (ID) Optional Code indicating the reason why a request was delayed Usage notes Data submitted in CLM20 will not be used for processing 1 Proof of Eligibility Unknown or Unavailable 2 Litigation 3 Authorization Delays 4 Delay in Certifying Provider 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 56 285 5 Delay in Supplying Billing Forms 6 Delay in Delivery of Custom-made Appliances 7 Third Party Processing Delay 8 Delay in Eligibility Determination 9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules 10 Administration Delay in the Prior Approval Process 11 Other 15 Natural Disaster 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 57 285 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Admission Date Hour To specify any or all of a date, a time, or | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_11 |
837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 57 285 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Admission Date Hour To specify any or all of a date, a time, or a time period Usage notes Required on inpatient claims. If not required by this implementation guide, do not send. Example DTP 435 D8 XXX Variants (all may be used) DTP Date - Repricer Received Date DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 435 Admission DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes Selection of the appropriate qualifier is designated by the NUBC Billing Manual. Must not be a future date. D8 Date Expressed in Format CCYYMMDD DT Date and Time Expressed in Format CCYYMMDDHHMM DTP-03 1251 Admission Date and Hour Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times Usage notes Must be in format HHMM.MM 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 58 285 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Date - Repricer Received Date To specify any or all of a date, a time, or a time period Usage notes Required when a repricer is passing the claim onto the payer. If not required by this implementation guide, do not send. Example DTP 050 D8 XXXXXX Variants (all may be used) DTP Admission Date Hour DTP Discharge Hour DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 050 Received DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Repricer Received Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 59 285 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Discharge Hour To specify any or all of a date, a time, or a time period Usage notes Required on all final inpatient claims. If not required by this implementation guide, do not send. Example DTP 096 TM XXXXXX Variants (all may be used) DTP Admission Date Hour DTP Date - Repricer Received Date DTP Statement Dates Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 096 Discharge DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. TM Time Expressed in Format HHMM DTP-03 1251 Discharge Time Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 60 285 DTP 1350 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop DTP Statement Dates To specify any or all of a date, a time, or a time period Example DTP 434 RD8 XXXXX Variants (all may be used) DTP Admission Date Hour DTP Date - Repricer Received Date DTP Discharge Hour Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 434 Statement DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD Use RD8 to indicate the from and through date of the statement. When the statement is for a single date of service, the from and through date are the same. DTP-03 1251 Statement From and To Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 61 285 CL1 1400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CL1 Institutional Claim Code To supply information specific to hospital claims Example CL1 X X XX Max use 1 Required CL1-01 1315 Admission Type Code Min 1 Max 1 Identifier (ID) Required Code indicating the priority of this admission CL1-02 1314 Admission Source Code Min 1 Max 1 Identifier (ID) Optional Code indicating the source of this admission CL1-03 1352 Patient Status Code Min 1 Max 2 Identifier (ID) Required Code indicating patient status as of the "statement covers through date" 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 62 285 PWK 1550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_12 |
01H25JDXFJR748R6M871MGNNCJ 62 285 PWK 1550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop PWK Claim Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Only the first iteration of the PWK, at either the claim level and or line level, will be considered in the claim adjudication. Example PWK A4 BM AC XX If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 63 285 BT Blanket Test Results CB Chiropractic Justification CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. FT File Transfer Required when the actual attachment is maintained by an attachment warehouse or similar vendor. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 64 285 FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 65 285 AMT 1750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop AMT Patient Estimated Amount Due To indicate the total monetary amount Usage notes Required when the Patient Responsibility Amount is applicable to this claim. If not required by this implementation guide, do not send. Example AMT F3 00000000000000 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount F3 Patient Responsibility - Estimated AMT-02 782 Patient Responsibility Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 66 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Adjusted Repriced Claim Number To specify identifying information Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF 9C XXXXXX Variants (all may be used) REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9C Adjusted Repriced Claim Reference Number REF-02 127 Adjusted Repriced Claim Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_13 |
Claim Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 67 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Auto Accident State To specify identifying information Usage notes Required when the services reported on this claim are related to an auto accident and the accident occurred in a country or location that has a state, province, or sub- country code named in code source 22. If not required by this implementation guide, do not send. Example REF LU X Variants (all may be used) REF Adjusted Repriced Claim Number REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LU Location Number REF-02 127 Auto Accident State or Province Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Values in this field must be valid codes found in code source 22. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 68 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Claim Identifier For Transmission Intermediaries To specify identifying information Usage notes Required when this information is deemed necessary by transmission intermediaries (Automated Clearinghouses, and others) who need to attach their own unique claim number. If not required by this implementation guide, do not send. Although this REF is supplied for transmission intermediaries to attach their own unique claim number to a claim, 837-recipients are not required under HIPAA to return this number in any HIPAA transaction. Trading partners may voluntarily agree to this interaction if they wish. Example REF D9 X Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification Usage notes Number assigned by clearinghouse, van, etc. D9 Claim Number REF-02 127 Value Added Network Trace Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 69 285 The value carried in this element is limited to a maximum of 20 positions. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 70 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Demonstration Project Identifier To specify identifying information Usage notes Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. Example REF P4 XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification P4 Project Code REF-02 127 Demonstration Project Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 71 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Investigational Device Exemption Number To specify identifying information Usage notes Required when claim involves a Food and Drug Administration (FDA) assigned investigational device exemption (IDE) number. When more than one IDE applies, they must be split into separate claims. If not required by this implementation guide, do not send. Example REF LX XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 5 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification LX Qualified Products List REF-02 127 Investigational Device Exemption Identifier String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 72 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_14 |
cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 72 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Medical Record Number To specify identifying information Usage notes Required when the provider needs to identify for future inquiries, the actual medical record of the patient identified in either Loop ID-2010BA or Loop ID-2010CA for this episode of care. If not required by this implementation guide, do not send. Example REF EA XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification EA Medical Record Identification Number REF-02 127 Medical Record Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 73 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Payer Claim Control Number To specify identifying information Usage notes Required when CLM05-3 (Claim Frequency Code) indicates this claim is a replacement or void to a previously adjudicated claim. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. Example REF F8 XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number REF-02 127 Payer Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 74 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Peer Review Organization (PRO) Approval Number To specify identifying information Usage notes Required when an external Peer Review Organization assigns an Approval Number to services deemed medically necessary by that organization. If not required by this implementation guide, do not send. Example REF G4 X Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Prior Authorization REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G4 Peer Review Organization (PRO) Approval Number REF-02 127 Peer Review Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 75 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Prior Authorization To specify identifying information Usage notes Generally, preauthorization numbers are assigned by the payer or UMO to authorize a service prior to its being performed. The UMO (Utilization Management Organization) is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information. The prior authorization number carried in this REF is specific to the destination payer reported in the Loop ID-2010BB. If other payers have similar numbers for this claim, report that information in the Loop ID-2330 loop REF which holds that payer's information. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Required when an authorization number is assigned by the payer or UMO AND the services on this claim were preauthorized. If not required by this implementation guide, do not send. Example REF G1 XXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Referral Number REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 76 285 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 77 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_15 |
77 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Referral Number To specify identifying information Usage notes Required when a referral number is assigned by the payer or Utilization Management Organization (UMO) AND a referral is involved. If not required by this implementation guide, do not send. Numbers at this position apply to the entire claim unless they are overridden in the REF segment in Loop ID-2400. A reference identification is considered to be overridden if the value in REF01 is the same in both the Loop ID-2300 REF segment and the Loop ID-2400 REF segment. In that case, the Loop ID-2400 REF applies only to that specific line. Example REF 9F XXXXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Repriced Claim Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Referral Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 78 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Repriced Claim Number To specify identifying information Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. Example REF 9A XX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Service Authorization Exception Code Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9A Repriced Claim Reference Number REF-02 127 Repriced Claim Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 79 285 REF 1800 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop REF Service Authorization Exception Code To specify identifying information Usage notes Required when mandated by government law or regulation to obtain authorization for specific service(s) but, for the reasons listed in REF02, the service was performed without obtaining the authorization. If not required by this implementation guide, do not send. Example REF 4N XXXX Variants (all may be used) REF Adjusted Repriced Claim Number REF Auto Accident State REF Claim Identifier For Transmission Intermediaries REF Demonstration Project Identifier REF Investigational Device Exemption Number REF Medical Record Number REF Payer Claim Control Number REF Peer Review Organization (PRO) Approval Number REF Prior Authorization REF Referral Number REF Repriced Claim Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 4N Special Payment Reference Number REF-02 127 Service Authorization Exception Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Allowable values for this element are: 1 Immediate Urgent Care 2 Services Rendered in a Retroactive Period 3 Emergency Care 4 Client has Temporary Medicaid 5 Request from County for Second Opinion to Determine if Recipient Can Work 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 80 285 6 Request for Override Pending 7 Special Handling 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 81 285 K3 1850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop K3 File Information To transmit a fixed-format record or matrix contents Usage notes Required when ALL of the following conditions are met: A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement; The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement X12N determines that there is no method to meet the requirement. If not required by this implementation guide, do not send. At the time of publication of this implementation, K3 segments have no specific use. The K3 segment is expected to be used only when necessary to meet the unexpected data requirement of a legislative authority. Before this segment can be used: The X12N Health Care Claim workgroup must conclude there is no other available option in the implementation guide to meet the emergency legislative requirement. The requestor must submit a proposal for approval accompanied by the relevant business documentation to the X12N Health Care Claim workgroup chairs and receive approval for the request. Upon review of the request, X12N will issue an approval or denial decision to the requesting entity. Approved usage(s) of the K3 segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_16 |
segment will be reviewed by the X12N Health Care Claim workgroup to develop a permanent change to include the business case in future transaction implementations. Only when all of the requirements above have been met, may the regulatory agency require the temporary use of the K3 segment. X12N will submit the necessary data maintenance and refer the request to the appropriate data content committee(s). Example K3 X Max use 10 Optional K3-01 449 Fixed Format Information Min 1 Max 80 String (AN) Required Data in fixed format agreed upon by sender and receiver 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 82 285 NTE 1900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop NTE Billing Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. If not required by this implementation guide, do not send. Example NTE ADD XXXXXX Variants (all may be used) NTE Claim Note Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ADD Additional Information NTE-02 352 Billing Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 83 285 NTE 1900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop NTE Claim Note To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when in the judgment of the provider, the information is needed to substantiate the medical treatment and is not supported elsewhere within the claim data set. OR Required when in the judgment of the provider, narrative information from the forms "Home Health Certification and Plan of Treatment" or "Medical Update and Patient Information" is needed to substantiate home health services. If not required by this implementation guide, do not send. The developers of this implementation guide discourage using narrative information within the 837. Trading partners who use narrative information with claims are strongly encouraged to codify that information within the X12 environment.; Example NTE RLH XXXXX Variants (all may be used) NTE Billing Note Max use 10 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies ALG Allergies DCP Goals, Rehabilitation Potential, or Discharge Plans DGN Diagnosis Description DME Durable Medical Equipment (DME) and Supplies MED Medications NTR Nutritional Requirements ODT Orders for Disciplines and Treatments RHB Functional Limitations, Reason Homebound, or Both RLH Reasons Patient Leaves Home RNH Times and Reasons Patient Not at Home SET Unusual Home, Social Environment, or Both SFM Safety Measures SPT Supplementary Plan of Treatment UPI Updated Information NTE-02 352 Claim Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 84 285 CRC 2200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop CRC EPSDT Referral To supply information on conditions Usage notes Required on Early Periodic Screening, Diagnosis, and Treatment (EPSDT) claims when the screening service is being billed in this claim. If not required by this implementation guide, do not send. Example CRC ZZ Y NU XXX XX Max use 1 Optional CRC-01 1136 Code Qualifier Identifier (ID) Required Specifies the situation or category to which the code applies CRC01 qualifies CRC03 through CRC07. ZZ Mutually Defined EPSDT Screening referral information. CRC-02 1073 Certification Condition Code Applies Indicator Identifier (ID) Required Code indicating a Yes or No condition or response CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply. Usage notes The response answers the question: Was an EPSDT referral given to the patient? N No If no, then choose "NU" in CRC03 indicating no referral given. Y Yes CRC-03 1321 Condition Indicator Identifier (ID) Required Code indicating a condition Usage notes The codes for CRC03 also can be used for CRC04 through CRC05. AV Available - Not Used Patient refused referral. NU Not Used This conditioner indicator must be used when the submitter answers "N" in CRC02. S2 Under Treatment Patient is currently under treatment for referred diagnostic or corrective health problem. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 85 285 ST New Services Requested Patient is referred to another provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals). OR Patient is scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (not including dental referrals).; CRC-04 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. CRC-05 1321 Condition Indicator Min 2 Max 3 Identifier (ID) Optional Code indicating a condition Usage notes Use the codes listed in CRC03. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 86 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Admitting Diagnosis To supply information related to the delivery of health care Usage notes Required when claim involves an inpatient admission. If not required by this implementation | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_17 |
guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 86 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Admitting Diagnosis To supply information related to the delivery of health care Usage notes Required when claim involves an inpatient admission. If not required by this implementation guide, do not send.; Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BJ XXXX Variants (all may be used) HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABJ International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BJ International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis C022-02 1271 Admitting Diagnosis Code Min 1 Max 30 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 87 285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 88 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Condition Information To supply information related to the delivery of health care Usage notes Required when there is a Condition Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BG XXXXX BG XXXXX BG XXXXXX BG XXX BG XX B G X BG XXXX BG XXXXX BG XX BG XXXXXX BG XXXX BG X XXXX Variants (all may be used) HI Admitting Diagnosis HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 89 285 Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 90 285 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_18 |
If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 91 285 BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 92 285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 93 285 Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional condition code and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_19 |
and the preceding HI data elements have been used to report other condition codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BG Condition C022-02 1271 Condition Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 94 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Diagnosis Related Group (DRG) Information To supply information related to the delivery of health care Usage notes Required when an inpatient hospital is under DRG contract with a payer and the contract requires the provider to identify the DRG to the payer. If not required by this implementation guide, do not send. Example HI DR XXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. DR Diagnosis Related Group (DRG) C022-02 1271 Diagnosis Related Group (DRG) Code String (AN) Required Min 1 Max 30 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 95 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI External Cause of Injury To supply information related to the delivery of health care Usage notes Required when an external Cause of Injury is needed to describe an injury, poisoning, or adverse effect. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. In order to fully describe an injury using ICD-10-CM, it will be necessary to report a series of 3 external cause of injury codes. Example HI ABN X N ABN XXXXXX Y BN X N BN XXXXXX U BN X W BN XXX W BN XXXX N BN XXX U BN XXXXX U ABN XXX N BN X N ABN XXXXXX U Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 96 285 the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_20 |
is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 97 285 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 98 285 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 99 285 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_21 |
given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 100 285 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 101 285 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 102 285 The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_22 |
a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 103 285 OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 104 285 BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 105 285 ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_23 |
set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 106 285 This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional External Cause of Injury must be sent and the preceding HI data elements have been used to report other causes of injury. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABN International Classification of Diseases Clinical Modification (ICD-10-CM) External Cause of Injury Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 107 285 If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BN International Classification of Diseases Clinical Modification (ICD-9-CM) External Cause of Injury Code (E-codes) C022-02 1271 External Cause of Injury Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 108 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Occurrence Information To supply information related to the delivery of health care Usage notes Required when there is a Occurrence Code | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_24 |
Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 108 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Occurrence Information To supply information related to the delivery of health care Usage notes Required when there is a Occurrence Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BH XXXXX D8 XXXX BH XXXXXX D8 XXXXXX BH XXXX X D8 XXXXX BH X D8 XXXXXX BH XXXXXX D8 XX BH XX D 8 X BH XXXXX D8 XXX BH XXXXX D8 XXXX BH XXX D8 XX X BH XX D8 XXXXXX BH XXXXXX D8 X BH XXXXXX D8 XX X Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 109 285 C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 110 285 Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 111 285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_25 |
codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 112 285 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 113 285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 114 285 Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_26 |
C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 115 285 BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 116 285 C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence code and the preceding HI data elements have been used to report other occurrence codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BH Occurrence C022-02 1271 Occurrence Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Occurrence Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 117 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Occurrence Span Information To supply information related to the delivery of health care Usage notes Required when there is an Occurrence Span Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BI XXXXX RD8 XX BI XXXXX RD8 XX BI XXXX RD8 XX X BI XXXX RD8 XXXXX BI XX RD8 XXXXXX BI X RD8 XX X BI XX RD8 XXXX BI XXXX RD8 XXX BI XXX RD8 XXXXX X BI XX RD8 XXXXXX BI XXX RD8 XXX BI XX RD8 XX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 118 285 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_27 |
RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 119 285 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 120 285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 121 285 Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_28 |
BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 122 285 BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 123 285 C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 124 285 C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_29 |
associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 125 285 RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional occurrence span code and the preceding HI data elements have been used to report other occurrence span codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BI Occurrence Span C022-02 1271 Occurrence Span Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD C022-04 1251 Occurrence Span Code Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 126 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Other Diagnosis Information To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Required when other condition(s) coexist or develop(s) subsequently during the patient's treatment. If not required by this implementation guide, do not send. Example HI ABF XXXX W BF XXXX Y BF XXX W BF XX N ABF X W BF XX U BF X XX N ABF XXX U BF XXXX W BF XXX XX Y ABF XXXXX N ABF XXXX W Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 127 285 BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_30 |
list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 128 285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 129 285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 130 285 Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_31 |
Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 131 285 an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 132 285 C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_32 |
need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 133 285 N No U Unknown W Not Applicable Y Yes HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 134 285 Y Yes HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-10 C022 Health Care Code Information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 135 285 To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_33 |
C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 136 285 Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 137 285 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABF International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BF International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis C022-02 1271 Other Diagnosis Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 138 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Other Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when additional procedures must be reported. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BBQ XXXXXX D8 X BBQ XXX D8 XXXX BBQ XXX D8 XXX XXX BQ XXXXX D8 XXXX BQ XXXXX D8 XXXX BQ XXXXXX D 8 XXXXXX BBQ XXXX D8 XXX BQ XX D8 XXX BBQ XXXX D 8 XXXX BBQ XX D8 XXXXX BBQ XXXXX D8 XXXXX BBQ XX X D8 XXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_34 |
Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 139 285 OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 140 285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 141 285 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_35 |
under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 142 285 Expression of a date, a time, or range of dates, times or dates and times HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 143 285 Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 144 285 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_36 |
If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 145 285 OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 146 285 C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 147 285 Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_37 |
codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 148 285 Expression of a date, a time, or range of dates, times or dates and times HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional procedure and the preceding HI data elements have been used to report other procedures. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BBQ International Classification of Diseases Clinical Modification (ICD-10-PCS) Other Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BQ International Classification of Diseases Clinical Modification (ICD-9-CM) Other Procedure Codes C022-02 1271 Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 149 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Patient's Reason For Visit To supply information related to the delivery of health care Usage notes Required when claim involves outpatient visits. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI PR XXXXX APR XXX APR XX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 150 285 APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_38 |
Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 151 285 HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when an additional Patient's Reason for Visit must be sent and the preceding HI data elements have been used to report other patient's reason for visit. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. APR International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. PR International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit C022-02 1271 Patient Reason For Visit Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 152 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Principal Diagnosis To supply information related to the delivery of health care Usage notes Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI BK XXXXX N Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Procedure Information HI Treatment Code Information HI Value Information Max use 1 Required HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. ABK International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-CM as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BK International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis C022-02 1271 Principal Diagnosis Code Min 1 Max 30 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 153 285 Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-09 1073 Present on Admission Indicator Identifier (ID) Optional Code indicating a Yes or No condition or response C022-09 is used to identify the diagnosis onset as it relates to the diagnosis reported in C022-02. A "Y" indicates that the onset occurred prior to admission to the hospital; an "N" indicates that the onset did NOT occur prior to admission to the hospital; a "U" indicates that it is unknown whether the onset occurred prior to admission to the hospital or not. C022-09 would only need to be reported to data collectors requiring this information when C022-01 is "BF" (Diagnosis Code) and range of diagnosis codes were NOT given in C022-08. N No U Unknown W Not Applicable Y Yes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 154 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Principal Procedure Information To supply information related to the delivery of health care Usage notes Required on inpatient claims when a procedure was performed. If not required by this implementation guide, do not send. Do not transmit the decimal point for ICD codes. The decimal point is implied. Example HI CAH XXXX D8 XXXX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Treatment Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_39 |
Code Information HI Value Information Max use 1 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 155 285 BBR International Classification of Diseases Clinical Modification (ICD-10-PCS) Principal Procedure Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the ICD-10-PCS as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. BR International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure Codes CAH Advanced Billing Concepts (ABC) Codes C022-02 1271 Principal Procedure Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-03 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format C022-03 is the date format that will appear in C022-04. D8 Date Expressed in Format CCYYMMDD C022-04 1251 Principal Procedure Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 156 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Treatment Code Information To supply information related to the delivery of health care Usage notes Required when Home Health Agencies need to report Plan of Treatment information under various payer contracts. If not required by this implementation guide, do not send. Example HI TC X TC X TC XX TC XX TC XX TC XX TC X TC XXXX X TC X TC XXXXX TC XX TC XX Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Value Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 157 285 Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 158 285 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_40 |
to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 159 285 TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 160 285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 161 285 Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional treatment code and the preceding HI data elements have been used to report other treatment codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_41 |
Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. TC Treatment Codes C022-02 1271 Treatment Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 162 285 HI 2310 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HI Value Information To supply information related to the delivery of health care Usage notes Required when there is a Value Code that applies to this claim. If not required by this implementation guide, do not send. Example HI BE XXX 0000000000 BE XX 0000 BE XXXXXX 0 00000000000000 BE XXXXX 000 BE XX 00000000000 000 BE XXXX 0 BE XXXXX 000000000000 BE XXXX 000000 BE XXXXX 000000 BE XXX 0000 BE X 00 000 BE XX 00000 Variants (all may be used) HI Admitting Diagnosis HI Condition Information HI Diagnosis Related Group (DRG) Information HI External Cause of Injury HI Occurrence Information HI Occurrence Span Information HI Other Diagnosis Information HI Other Procedure Information HI Patient's Reason For Visit HI Principal Diagnosis HI Principal Procedure Information HI Treatment Code Information Max use 2 Optional HI-01 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Max use 1 Required C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 163 285 C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-02 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-03 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 164 285 If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-04 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-05 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 165 285 C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-06 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_42 |
amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-07 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 166 285 BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-08 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-09 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 167 285 Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-10 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-11 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 168 285 C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount HI-12 C022 Health Care Code Information To send health care codes and their associated dates, amounts and quantities Usage notes Required when it is necessary to report an additional value code and the preceding HI data elements have been used to report other value codes. If not required by this implementation guide, do not send. Max use 1 Optional C022-01 1270 Code List Qualifier Code Identifier (ID) Required Code identifying a specific industry code list C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08. BE Value C022-02 1271 Value Code Min 1 Max 30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_43 |
30 String (AN) Required Code indicating a code from a specific industry code list If C022-08 is used, then C022-02 represents the beginning value in a range of codes. C022-05 782 Value Code Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 169 285 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 170 285 HCP 2410 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop HCP Claim Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP 11 000000000000000 00000000000000 XXXXX 00000 0000 XX 0 XXX UN 00 T4 5 1 If either Unit or Basis for Measurement Code (HCP-11) or Repriced Approved Service Unit Count (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Repriced Allowed Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 171 285 HCP02 is the allowed amount. HCP-03 782 Repriced Saving Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Repricing Organization Identifier Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Repricing Per Diem or Flat Rate Amount Decimal number (R) Optional Min 1 Max 9 Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Repriced Approved DRG Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Repriced Approved Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 172 285 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Repriced Approved Revenue Code Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Repriced Approved Service Unit Count Decimal number (R) Optional Min 1 Max 15 Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 173 285 This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_44 |
Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 174 285 2310A Attending Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Attending Provider Name Loop NM1 Attending Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the claim contains any services other than non-scheduled transportation claims. If not required by this implementation guide, do not send. The Attending Provider is the individual who has overall responsibility for the patient's medical care and treatment reported in this claim. Example NM1 71 1 XXXXX XXX XXX XXXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Attending Provider Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 71 Attending Physician When used, the term physician is any type of provider filling this role. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Attending Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Attending Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 175 285 Individual first name NM1-05 1037 Attending Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Attending Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Attending Provider Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 176 285 PRV 2550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Attending Provider Name Loop PRV Attending Provider Specialty Information To specify the identifying characteristics of a provider Usage notes Required when adjudication of the destination payer, or any subsequent payer listed on this claim, is known to be impacted by the attending provider taxonomy code. If not required by this implementation guide, do not send. Example PRV AT PXC XXXX Max use 1 Optional PRV-01 1221 Provider Code Identifier (ID) Required Code identifying the type of provider AT Attending PRV-02 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification PXC Health Care Provider Taxonomy Code PRV-03 127 Provider Taxonomy Code Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 177 285 2310A Attending Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Attending Provider Name Loop REF Attending Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF 1G XX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Attending Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 178 285 2310B Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Operating Physician Name Loop NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_45 |
Name Loop NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 72 1 XXXX XXXXX XXXXXX XX XX XXXXX If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 179 285 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 180 285 2310B Operating Physician Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Operating Physician Name Loop REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF 1G XXXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 181 285 2310C Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Operating Physician Name Loop NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved. If not required by the implementation guide, do not send. The Other Operating Physician is the individual performing a secondary surgical procedure or assisting the Operating Physician. This Other Operating Physician segment can only be used when Operating Physician information (Loop ID-2310B) is also sent on this claim. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 ZZ 1 XXXX XXXXX XX XX XX XXXXXX If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 182 285 Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Other Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 183 285 2310C Other Operating Physician Name | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_46 |
Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 183 285 2310C Other Operating Physician Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Operating Physician Name Loop REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF G2 XX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 184 285 2310D Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Service Facility Location Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. AND When state or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 82 1 XXXXXX XXX X XXXXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 185 285 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 186 285 2310D Rendering Provider Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. Example REF LU XXXXXX Max use 4 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 187 285 2310E Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_47 |
https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 187 285 2310E Service Facility Location Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop NM1 Service Facility Location Name To supply the full name of an individual or organizational entity Usage notes Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider's NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. Example NM1 77 2 XXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Laboratory or Facility Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 77 Service Location NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Laboratory or Facility Name Min 1 Max 60 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 188 285 Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Laboratory or Facility Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 189 285 N3 2650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N3 Service Facility Location Address To specify the location of the named party Usage notes If service facility location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, "crossroad of State Road 34 and 45" or "Exit near Mile marker 265 on Interstate 80".) Example N3 XX XXXXXX Max use 1 Required N3-01 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Laboratory or Facility Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 190 285 N4 2700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop N4 Service Facility Location City, State, ZIP Code To specify the geographic place of the named party Example N4 XXX XX XXX XXX Only one of Laboratory or Facility State or Province Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Required N4-01 19 Laboratory or Facility City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Laboratory or Facility State or Province Code Identifier (ID) Optional Min 2 Max 2 Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Laboratory or Facility Postal Zone or ZIP Code Identifier (ID) Optional Min 3 Max 15 Code defining international postal zone code excluding punctuation and blanks (zip code for United States) Usage notes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 191 285 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 192 285 2310E Service Facility Location Name Loop end REF 2710 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Facility Location Name Loop REF Service Facility Location Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI implementation date when the entity is not a Health Care provider (a.k.a. an atypical provider), and an identifier is necessary for the claims processor to identify the entity. If not required by this implementation guide, do not send. Example REF LU XXX Max use 3 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_48 |
Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Laboratory or Facility Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 193 285 2310F Referring Provider Name Loop Max 1 Optional Variants (all may be used) Attending Provider Name Loop Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop Service Facility Location Name Loop NM1 2500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Example NM1 DN 1 XXXXX XXXXXX XX XXX XX XXXXX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 194 285 2310F Referring Provider Name Loop end Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 195 285 2320 Other Subscriber Information Loop Max 10 Optional SBR 2900 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop SBR Other Subscriber Information To record information specific to the primary insured and the insurance carrier for that insured Usage notes Required when other payers are known to potentially be involved in paying on this claim. If not required by this implementation guide, do not send. All information contained in Loop ID-2320 applies only to the payer identified in Loop ID-2330B of this iteration of Loop ID-2320. It is specific only to that payer. If information for an additional payer is necessary, repeat Loop ID-2320 with its respective 2330 Loops.; See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example SBR F 18 XXXXXX XXXXX 14 Max use 1 Required SBR-01 1138 Payer Responsibility Sequence Number Code Identifier (ID) Required Code identifying the insurance carrier's level of responsibility for a payment of a claim Usage notes Within a given claim, the various values for the Payer Responsibility Sequence Number Code (other than value "U") may occur no more than once. The SBR must contain a different value in each iteration of the SBR01. Each value may only be used one time per claim. A Payer Responsibility Four B Payer Responsibility Five C Payer Responsibility Six D Payer Responsibility Seven E Payer Responsibility Eight F Payer Responsibility Nine G Payer Responsibility Ten H Payer Responsibility Eleven P Primary S Secondary T Tertiary U Unknown This code may only be used in payer to payer COB claims when the original payer determined the presence of this coverage from eligibility files received from this payer or when the original claim did not provide the responsibility sequence for this payer. SBR-02 1069 Individual Relationship Code Identifier (ID) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 196 285 Code indicating the relationship between two individuals or entities SBR02 specifies the relationship to the person insured. 01 Spouse 18 Self 19 Child 20 Employee 21 Unknown 39 Organ Donor 40 Cadaver Donor 53 Life Partner G8 Other Relationship SBR-03 127 Insured Group or Policy Number Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier SBR03 is policy or group number. Usage notes This is not the number uniquely identifying the subscriber. The unique subscriber number is submitted in Loop 2330A-NM109 for this iteration of Loop ID-2320. SBR-04 93 Other Insured Group Name Min 1 Max 60 String (AN) Optional Free-form name SBR04 is plan name. SBR-09 1032 Claim Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_49 |
Filing Indicator Code Identifier (ID) Required Code identifying type of claim 11 Other Non-Federal Programs 12 Preferred Provider Organization (PPO) 13 Point of Service (POS) 14 Exclusive Provider Organization (EPO) 15 Indemnity Insurance 16 Health Maintenance Organization (HMO) Medicare Risk 17 Dental Maintenance Organization AM Automobile Medical BL Blue Cross Blue Shield CH Champus CI Commercial Insurance Co. DS Disability FI Federal Employees Program HM Health Maintenance Organization LM Liability Medical MC Medicaid OF Other Federal Program 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 197 285 Use code OF when submitting Medicare Part D claims. TV Title V VA Veterans Affairs Plan WC Workers' Compensation Health Claim ZZ Mutually Defined Use Code ZZ when Type of Insurance is not known. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 198 285 CAS 2950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop CAS Claim Level Adjustments To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the claim has been adjudicated by the payer identified in this loop, and the claim has claim level adjustment information. If not required by this implementation guide, do not send. Submitters must use this CAS segment to report prior payers' claim level adjustments that cause the amount paid to differ from the amount originally charged. Only one Group Code is allowed per CAS. If it is necessary to send more than one Group Code at the claim level, repeat the CAS segment. Codes and associated amounts must come from either paper remittance advice or 835s (Electronic Remittance Advice) received on the claim. When the information originates from a paper remittance advice that does not use the standard Claim Adjustment Reason Codes, the paper values must be converted to standard Claim Adjustment Reason Codes.; A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). CAS segment must not be present when 2000B SBR01 P Example CAS CR XXX 000000000000000 000000000000000 XXX X 0 0000000000 XXXX 0 0000000000000 XXX 0000 0 X X 00000000 000000000 XXXXX 0000000 000000000 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required Max use 5 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 199 285 If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 200 285 CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_50 |
Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 201 285 CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 202 285 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Payer Paid Amount To indicate the total monetary amount Usage notes Required when the claim has been adjudicated by the payer identified in Loop ID- 2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send.; Example AMT D 0000000 Variants (all may be used) AMT Coordination of Benefits (COB) Total Non-Covered Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount Usage notes Medicare requires that one occurrence of 2320 loop with an AMT segment where AMT01 D must be present when 2000B SBR01 S. D Payor Amount Paid AMT-02 782 Payer Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount Usage notes It is acceptable to show "0" as the amount paid. When Loop ID-2010AC is present, this is the amount the Medicaid agency actually paid. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 203 285 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Coordination of Benefits (COB) Total Non-Covered Amount To indicate the total monetary amount Usage notes Required when the destination payer's cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. Example AMT A8 000000000 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Remaining Patient Liability Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount A8 Noncovered Charges - Actual AMT-02 782 Non-Covered Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 204 285 AMT 3000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and provided claim level information only. OR Required when the Other Payer identified in Loop ID-2330B (of this iteration of Loop ID-2320) has adjudicated this claim and the provider received a paper remittance advice and the provider does not have the ability to report line item information. If not required by this implementation guide, do not send. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID-2320. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). This segment is not used if the line level (Loop ID-2430) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 00000000000000 Variants (all may be used) AMT Coordination of Benefits (COB) Payer Paid Amount AMT Coordination of Benefits (COB) Total Non-Covered Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 205 285 OI 3100 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop OI Other Insurance Coverage Information To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI N Y Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_51 |
To specify information associated with other health insurance coverage Usage notes All information contained in the OI segment applies only to the payer identified in Loop ID-2330B in this iteration of Loop ID-2320. Example OI N Y Max use 1 Required OI-03 1073 Benefits Assignment Certification Indicator Identifier (ID) Required Code indicating a Yes or No condition or response OI03 is 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. Usage notes This is a crosswalk from CLM08 when doing COB. This element answers the question whether or not the insured has authorized the plan to remit payment directly to the provider. N No W Not Applicable Use code W' when the patient refuses to assign benefits. Y Yes OI-06 1363 Release of Information Code Identifier (ID) Required Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations Usage notes This is a crosswalk from CLM09 when doing COB. The Release of Information response is limited to the information carried in this claim. I Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes Required when the provider has not collected a signature AND state or federal laws do not require a signature be collected. Y Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim Required when the provider has collected a signature. OR Required when state or federal laws require a signature be collected. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 206 285 MIA 3150 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop MIA Inpatient Adjudication Information To provide claim-level data related to the adjudication of Medicare inpatient claims Usage notes Required when inpatient adjudication information is reported in the remittance advice. OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MIA 000000000 000000000000000 00000000000 XXX 00 000 0000000000 000000000000 00000000000000 000000 0 0000 000000000 000000000 00000000000000 00 0000 000000000 00000000 0000000 0000000000000 X XXXX X XXXX XX 000000000000 Max use 1 Optional MIA-01 380 Covered Days or Visits Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity MIA01 is the covered days. MIA-03 380 Lifetime Psychiatric Days Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA03 is the lifetime psychiatric days. MIA-04 782 Claim DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA04 is the Diagnosis Related Group (DRG) amount. MIA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA05 is the Claim Payment Remark Code. See Code Source 411. MIA-06 782 Claim Disproportionate Share Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 207 285 MIA06 is the disproportionate share amount. MIA-07 782 Claim MSP Pass-through Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA07 is the Medicare Secondary Payer (MSP) pass-through amount. MIA-08 782 Claim PPS Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA08 is the total Prospective Payment System (PPS) capital amount. MIA-09 782 PPS-Capital FSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA09 is the Prospective Payment System (PPS) capital, federal specific portion, Diagnosis Related Group (DRG) amount. MIA-10 782 PPS-Capital HSP DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA10 is the Prospective Payment System (PPS) capital, hospital specific portion, Diagnosis Related Group (DRG), amount. MIA-11 782 PPS-Capital DSH DRG Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA11 is the Prospective Payment System (PPS) capital, disproportionate share, hospital Diagnosis Related Group (DRG) amount. MIA-12 782 Old Capital Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA12 is the old capital amount. MIA-13 782 PPS-Capital IME amount Min 1 Max 15 Decimal number (R) Optional Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 208 285 MIA13 is the Prospective Payment System (PPS) capital indirect medical education claim amount. MIA-14 782 PPS-Operating Hospital Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA14 is hospital specific Diagnosis Related Group (DRG) Amount. MIA-15 380 Cost Report Day Count Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity MIA15 is the cost report days. MIA-16 782 PPS-Operating Federal Specific DRG Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA16 is the federal specific Diagnosis Related Group (DRG) amount. MIA-17 782 Claim PPS Capital Outlier Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA17 is the Prospective Payment System (PPS) Capital Outlier amount. MIA-18 782 Claim Indirect Teaching Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA18 is the indirect teaching amount. MIA-19 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MIA19 is the professional component amount billed but not payable. MIA-20 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 209 285 MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_52 |
Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 209 285 MIA20 is the Claim Payment Remark Code. See Code Source 411. MIA-21 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA21 is the Claim Payment Remark Code. See Code Source 411. MIA-22 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA22 is the Claim Payment Remark Code. See Code Source 411. MIA-23 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MIA23 is the Claim Payment Remark Code. See Code Source 411. MIA-24 782 PPS-Capital Exception Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MIA24 is the capital exception amount. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 210 285 MOA 3200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop MOA Outpatient Adjudication Information To convey claim-level data related to the adjudication of Medicare claims not related to an inpatient setting Usage notes Required when outpatient adjudication information is reported in the remittance advice OR Required when it is necessary to report remark codes. If not required by this implementation guide, do not send. Example MOA 0000 0000 XXXX XXX X XXXX XXXXXX 000000000000 00 0000000 Max use 1 Optional MOA-01 954 Reimbursement Rate Min 1 Max 10 Decimal number (R) Optional Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0 through 100 ) MOA01 is the reimbursement rate. MOA-02 782 HCPCS Payable Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount MOA02 is the claim Health Care Financing Administration Common Procedural Coding System (HCPCS) payable amount. MOA-03 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA03 is the Claim Payment Remark Code. See Code Source 411. MOA-04 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA04 is the Claim Payment Remark Code. See Code Source 411. MOA-05 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 211 285 MOA05 is the Claim Payment Remark Code. See Code Source 411. MOA-06 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA06 is the Claim Payment Remark Code. See Code Source 411. MOA-07 127 Claim Payment Remark Code Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier MOA07 is the Claim Payment Remark Code. See Code Source 411. MOA-08 782 End Stage Renal Disease Payment Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA08 is the End Stage Renal Disease (ESRD) payment amount. MOA-09 782 Non-Payable Professional Component Billed Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount MOA09 is the professional component amount billed but not payable. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 212 285 2330A Other Subscriber Name Loop Max 1 Required Variants (all may be used) Other Payer Name Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop NM1 Other Subscriber Name To supply the full name of an individual or organizational entity Usage notes If the patient can be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified in this Other Subscriber's Name Loop ID-2330A.; If the patient is a dependent of the subscriber for this other coverage and cannot be uniquely identified to the Other Payer indicated in this iteration of Loop ID-2320 by a unique Member Identification Number, then the subscriber for this other coverage is identified in this Other Subscriber's Name Loop ID-2330A. See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 IL 1 XXXX X XXX XXXXX MI XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual IL Insured or Subscriber NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person 2 Non-Person Entity NM1-03 1035 Other Insured Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other Insured First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 213 285 Individual first name NM1-05 1037 Other Insured Middle Name Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_53 |
name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Other Insured Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) II Standard Unique Health Identifier for each Individual in the United States Required if the HIPAA Individual Patient Identifier is mandated use. If not required, use value MI' instead. MI Member Identification Number The code MI is intended to be the subscriber's identification number as assigned by the payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.) MI is also intended to be used in claims submitted to the Indian Health Service Contract Health Services (IHS CHS) Fiscal Intermediary for the purpose of reporting the Tribe Residency Code (Tribe County State). In the event that a Social Security Number (SSN) is also available on an IHS CHS claim, put the SSN in REF02. When sending the Social Security Number as the Member ID, it must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. NM1-09 67 Other Insured Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 214 285 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N3 Other Subscriber Address To specify the location of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N3 XXX XXXXX Max use 1 Optional N3-01 166 Other Insured Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Insured Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 215 285 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop N4 Other Subscriber City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the information is available. If not required by this implementation guide, do not send. Example N4 XXXXX XX XXXXX XX Only one of Other Insured State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Insured City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Insured State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Insured Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 216 285 Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 217 285 2330A Other Subscriber Name Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Subscriber Name Loop REF Other Subscriber Secondary Identification To specify identifying information Usage notes Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send. Example REF SY XXXXX Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification SY Social Security Number The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid. REF-02 127 Other Insured Additional Identifier Min 1 Max 9 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Must be 9 digits with no punctuation. First 3 digits cannot be higher than 272. Digits 1-3, 4-5, and 6-9 cannot be zeros. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 218 285 2330B Other Payer Name Loop Max 1 Required Variants (all may be used) Other Subscriber Name Loop NM1 3250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop NM1 Other Payer Name To supply the full name of an individual or organizational entity Usage notes See Crosswalking COB Data Elements section for more information on handling COB in the 837. Example NM1 PR 2 XX XV XXXXX Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Other Payer Last or Organization Name Min 1 Max 60 | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_54 |
Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual PR Payer NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 2 Non-Person Entity NM1-03 1035 Other Payer Last or Organization Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-08 66 Identification Code Qualifier Identifier (ID) Required Code designating the system method of code structure used for Identification Code (67) Usage notes Use code value "PI" when reporting Payor Identification. Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID). Prior to the mandated implementation date for Health Plan Identifier, willing trading partners may agree to: Follow a dual use approach in which both the HPID or OEID and the Payor Identification are sent. Send XV qualifier in NM108 with HPID or OEID in NM109 and the Payor Identification, that would have been sent using qualifier PI, in the corresponding REF 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 219 285 segment using qualifier 2U (Payer Identification Number). OR Follow an early implementation approach in which the HPID or OEID is sent in NM109. PI Payor Identification XV Centers for Medicare and Medicaid Services PlanID NM1-09 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code Usage notes When sending Line Adjudication Information for this payer, the identifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (Line Adjudication Information) must match this value.; 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 220 285 N3 3320 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N3 Other Payer Address To specify the location of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N3 XXXXX XX Max use 1 Optional N3-01 166 Other Payer Address Line Min 1 Max 55 String (AN) Required Address information N3-02 166 Other Payer Address Line Min 1 Max 55 String (AN) Optional Address information 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 221 285 N4 3400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop N4 Other Payer City, State, ZIP Code To specify the geographic place of the named party Usage notes Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send. Example N4 XXXXX XX XXXX XXX Only one of Other Payer State Code (N4-02) or Country Subdivision Code (N4-07) may be present If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required Max use 1 Optional N4-01 19 Other Payer City Name Min 2 Max 30 String (AN) Required Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location. N4-02 156 Other Payer State Code Min 2 Max 2 Identifier (ID) Optional Code (Standard State Province) as defined by appropriate government agency N402 is required only if city name (N401) is in the U.S. or Canada. N4-03 116 Other Payer Postal Zone or ZIP Code Min 3 Max 15 Identifier (ID) Optional Code defining international postal zone code excluding punctuation and blanks (zip code for United States) N4-04 26 Country Code Min 2 Max 3 Identifier (ID) Optional Code identifying the country Usage notes Use the alpha-2 country codes from Part 1 of ISO 3166. N4-07 1715 Country Subdivision Code Min 1 Max 3 Identifier (ID) Optional Code identifying the country subdivision Usage notes Use the country subdivision codes from Part 2 of ISO 3166. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 222 285 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 223 285 DTP 3500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop DTP Claim Check or Remittance Date To specify any or all of a date, a time, or a time period Usage notes Required when the payer identified in this loop has previously adjudicated the claim and Loop ID-2430, Line Check or Remittance Date, is not used. If not required by this implementation guide, do not send.; Example DTP 573 D8 XXXXXX Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times Usage notes Must not be future date. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 224 285 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Adjustment Indicator To specify identifying information | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_55 |
Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 224 285 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Adjustment Indicator To specify identifying information Usage notes Required when the claim is being sent in the payer-to-payer COB model, AND the destination payer is secondary to the payer identified in this Loop ID-2330B, AND the payer identified in this Loop ID-2330B has re-adjudicated the claim. If not required by this implementation guide, do not send. Example REF T4 XXXXX Variants (all may be used) REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification T4 Signal Code REF-02 127 Other Payer Claim Adjustment Indicator Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes Only allowed value is "Y". 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 225 285 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Claim Control Number To specify identifying information Usage notes Required when it is necessary to identify the Other Payer's Claim Control Number in a payer-to-payer COB situation. OR Required when the Other Payer's Claim Control Number is available. If not required by this implementation guide, do not send. Example REF F8 X Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Prior Authorization Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification F8 Original Reference Number This is the payer's internal Claim Control Number for this claim for the payer identified in this iteration of Loop ID-2330. This value is typically used in payer-to-payer COB situations only. REF-02 127 Other Payer's Claim Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 226 285 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Prior Authorization Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a prior authorization number to this claim. If not required by this implementation guide, do not send. Example REF G1 XXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Referral Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification G1 Prior Authorization Number REF-02 127 Other Payer Prior Authorization Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 227 285 REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Referral Number To specify identifying information Usage notes Required when the payer identified in this loop has assigned a referral number to this claim. If not required by this implementation guide, do not send. Example REF 9F XXXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Secondary Identifier Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9F Referral Number REF-02 127 Other Payer Prior Authorization or Referral Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 228 285 2330B Other Payer Name Loop end 2320 Other Subscriber Information Loop end REF 3550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Other Subscriber Information Loop Other Payer Name Loop REF Other Payer Secondary Identifier To specify identifying information Usage notes Required when an additional identification number to that provided in the NM109 of this loop is necessary to identify the entity. If not required by this implementation guide, do not send. Example REF FY XXX Variants (all may be used) REF Other Payer Claim Adjustment Indicator REF Other Payer Claim Control Number REF Other Payer Prior Authorization Number REF Other Payer Referral Number Max use 2 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number This code is only allowed when the qualifier XV is reported in NM108 of this loop. EI Employer's Identification Number The Employer's Identification Number must be a string of exactly nine numbers with no separators. For example, "001122333" would be valid, while sending "001-12-2333" or "00-1122333" would be invalid. FY Claim Office Number NF National Association of Insurance Commissioners (NAIC) Code REF-02 127 Other Payer Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 229 285 2400 | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_56 |
Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 229 285 2400 Service Line Number Loop Max 999 Required LX 3650 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop LX Service Line Number To reference a line number in a transaction set Usage notes The LX functions as a line counter. The Service Line LX segment must begin with one and is incremented by one for each additional service line of a claim. LX01 is used to indicate bundling in SVD06 in the Line Item Adjudication loop. See Section 1.4.1.2 for more information on bundling and unbundling. Example LX 0 Max use 1 Required LX-01 554 Assigned Number Min 1 Max 6 Numeric (N0) Required Number assigned for differentiation within a transaction set Usage notes LX01 must be greater than zero and less than or equal to 449. An individual claim with service lines greater than 449 will be rejected (However, the transmission of claims will be accepted, per HIPAA). 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 230 285 SV2 3750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop SV2 Institutional Service Line To specify the service line item detail for a health care institution Example SV2 XXXX HC X XX XX XX XX XXXXXX 0000 UN 0 00000 0 Max use 1 Required SV2-01 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SV201 is the revenue code. Usage notes See Code Source 132: National Uniform Billing Committee (NUBC) Codes. SV2-02 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers Usage notes Required for outpatient claims when an appropriate procedure code exists for this service line item. OR Required for inpatient claims when an appropriate HCPCS (drugs and or biologics only) or HIPPS code exists for this service line item. If not required by this implementation guide, do not send.; Max use 1 Optional C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. Usage notes If A0427, A0428 (with a QL modifier in SV202-3, SV202-4, SV202-5, or SV202-6), A0425, A0429, A0430, A0431, A0432, A0433, A0434, A0435, 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 231 285 A0488, or A0436 (nonscheduled transportation claim) are the only codes present, 2310A NM1 must not be preset. Otherwise, 2310A NM1 must be present. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-06 modifies the value in C003-02 and C003-08. C003-07 352 Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SV2-03 782 Line Item Charge Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SV203 is the submitted service line item amount. Usage notes This is the total charge amount for this service line. The amount is inclusive of the provider's base charge and any applicable tax amounts reported within this line's AMT segments. Zero "0" is an acceptable value for this element. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 232 285 SV203 must be greater than zero. SV203 s decimal positions are limited to 0, 1, or 2. SV2-04 355 Unit or Basis for Measurement Code Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit SV2-05 380 Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SV205 must be greater than zero and less than or equal to 999,999.9. Must be 0 or 1 decimal position. SV2-07 782 Line Item Denied Charge or Non-Covered Charge Amount Decimal number (R) Optional Min 1 Max 15 Monetary amount SV207 is a non-covered service amount. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 233 285 PWK 4200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_57 |
Optional Min 1 Max 15 Monetary amount SV207 is a non-covered service amount. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 233 285 PWK 4200 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop PWK Line Supplemental Information To identify the type or transmission or both of paperwork or supporting information Usage notes Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider's office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of "AA" in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. Example PWK 10 FX AC XXXXXXX If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required Max use 10 Optional PWK-01 755 Attachment Report Type Code Identifier (ID) Required Code indicating the title or contents of a document, report or supporting item 03 Report Justifying Treatment Beyond Utilization Guidelines 04 Drugs Administered 05 Treatment Diagnosis 06 Initial Assessment 07 Functional Goals 08 Plan of Treatment 09 Progress Report 10 Continued Treatment 11 Chemical Analysis 13 Certified Test Report 15 Justification for Admission 21 Recovery Plan A3 Allergies Sensitivities Document A4 Autopsy Report AM Ambulance Certification AS Admission Summary B2 Prescription B3 Physician Order B4 Referral Form BR Benchmark Testing Results BS Baseline BT Blanket Test Results CB Chiropractic Justification 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 234 285 CK Consent Form(s) CT Certification D2 Drug Profile Document DA Dental Models DB Durable Medical Equipment Prescription DG Diagnostic Report DJ Discharge Monitoring Report DS Discharge Summary EB Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor) HC Health Certificate HR Health Clinic Records I5 Immunization Record IR State School Immunization Records LA Laboratory Results M1 Medical Record Attachment MT Models NN Nursing Notes OB Operative Note OC Oxygen Content Averaging Report OD Orders and Treatments Document OE Objective Physical Examination (including vital signs) Document OX Oxygen Therapy Certification OZ Support Data for Claim P4 Pathology Report P5 Patient Medical History Document PE Parenteral or Enteral Certification PN Physical Therapy Notes PO Prosthetics or Orthotic Certification PQ Paramedical Results PY Physician's Report PZ Physical Therapy Certification RB Radiology Films RR Radiology Reports RT Report of Tests and Analysis Report RX Renewable Oxygen Content Averaging Report SG Symptoms Document V5 Death Notification XP Photographs PWK-02 756 Attachment Transmission Code Identifier (ID) Required Code defining timing, transmission method or format by which reports are to be sent AA Available on Request at Provider Site This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request. BM By Mail EL Electronically Only Indicates that the attachment is being transmitted in a separate X12 functional group. EM E-Mail FT File Transfer 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 235 285 Required when the actual attachment is maintained by an attachment warehouse or similar vendor. FX By Fax PWK-05 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) PWK05 and PWK06 may be used to identify the addressee by a code number. AC Attachment Control Number PWK-06 67 Attachment Control Number Min 2 Max 80 String (AN) Optional Code identifying a party or other code Usage notes PWK06 is used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. For the purpose of this implementation, the maximum field length is 50. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 236 285 DTP 4550 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop DTP Date - Service Date To specify any or all of a date, a time, or a time period Usage notes Required on outpatient service lines where a drug is not being billed and the Statement Covers Period is greater than one day. OR Required on service lines where a drug is being billed and the payer's adjudication is known to be impacted by the drug duration or the date the prescription was written. If not required by this implementation guide, do not send. In cases where a drug is being billed on a service line, date range may be used to indicate drug duration for which the drug supply will be used by the patient. The difference in dates, including both the begin and end dates, are the days supply of the drug. Example: 20000101 - 20000107 (1 1 00 to 1 7 00) is used for a 7 day supply where the first day of the drug used by the patient is 1 1 00. In the event a drug is administered on less than a daily basis (for example, every other day) the date range would include the entire period during which the drug was supplied, including the last day the drug was used. Example: 20000101 - 20000108 (1 1 00 to 1 8 00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_58 |
including the last day the drug was used. Example: 20000101 - 20000108 (1 1 00 to 1 8 00) is used for an 8 days supply where the prescription is written for Q48 (every 48 hours), four doses of the drug are dispensed and the first dose is used on 1 1 00. In cases where a drug is being billed on a service line, a single date may be used to indicate the date the prescription was written (or otherwise communicated by the prescriber if not written). Example DTP 472 D8 XX Max use 1 Optional DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 472 Service DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. Usage notes RD8 is required only when the "To and From" dates are different. However, at the discretion of the submitter, RD8 can also be used when the "To and From" dates are the same. D8 Date Expressed in Format CCYYMMDD RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD DTP-03 1251 Service Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 237 285 Usage notes Must not be a future date, except for type of bill 0322 after 1 1 2021 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 238 285 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Adjusted Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on an adjusted service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9D XXX Variants (all may be used) REF Line Item Control Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9D Adjusted Repriced Line Item Reference Number REF-02 127 Adjusted Repriced Line Item Reference Number String (AN) Required Min 1 Max 50 Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 239 285 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Line Item Control Number To specify identifying information Usage notes Required when the submitter needs a line item control number for subsequent communications to or from the payer. If not required by this implementation guide, do not send. The line item control number must be unique within a patient control number (CLM01). Payers are required to return this number in the remittance advice transaction (835) if the provider sends it to them in the 837 and adjudication is based upon line item detail regardless of whether bundling or unbundling has occurred. Submitters are STRONGLY encouraged to routinely send a unique line item control number on all service lines, particularly if the submitter automatically posts their remittance advice. Submitting a unique line item control number allows the capability to automatically post by service line. Example REF 6R XXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Repriced Line Item Reference Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 6R Provider Control Number REF-02 127 Line Item Control Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The maximum number of characters to be supported for this field is 30'. A submitter may submit fewer characters depending upon their needs. However, the HIPAA maximum requirement to be supported by any receiving system is 30'. Characters beyond 30 are not required to be stored nor returned by any 837-receiving system. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 240 285 REF 4700 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop REF Repriced Line Item Reference Number To specify identifying information Usage notes Required when a repricing (pricing) organization needs to have an identifying number on the service line in their submission to their payer organization. This segment is not completed by providers. If not required by this implementation guide, do not send. Example REF 9B XXXXX Variants (all may be used) REF Adjusted Repriced Line Item Reference Number REF Line Item Control Number Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 9B Repriced Line Item Reference Number REF-02 127 Repriced Line Item Reference Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 241 285 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Facility Tax Amount To indicate the total monetary amount Usage notes Required when a facility tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_59 |
Line Number Loop AMT Facility Tax Amount To indicate the total monetary amount Usage notes Required when a facility tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Facility Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Facility Tax Amount. Example AMT N8 0 Variants (all may be used) AMT Service Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount N8 Miscellaneous Taxes AMT-02 782 Facility Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 242 285 AMT 4750 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop AMT Service Tax Amount To indicate the total monetary amount Usage notes Required when a service tax or surcharge applies to the service being reported in SV201 and the submitter is required to report that information to the receiver. If not required by this implementation guide, do not send. When reporting the Service Tax Amount (AMT02), the amount reported in the Line Item Charge Amount (SV203) for this service line must include the amount reported in the Service Tax Amount. Example AMT GT 000000000000000 Variants (all may be used) AMT Facility Tax Amount Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount GT Goods and Services Tax AMT-02 782 Service Tax Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 243 285 NTE 4850 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop NTE Third Party Organization Notes To transmit information in a free-form format, if necessary, for comment or special instruction Usage notes Required when the TPO repricer needs to forward additional information to the payer. This segment is not completed by providers. If not required by this implementation guide, do not send. Example NTE TPO XX Max use 1 Optional NTE-01 363 Note Reference Code Identifier (ID) Required Code identifying the functional area or purpose for which the note applies TPO Third Party Organization Notes NTE-02 352 Line Note Text Min 1 Max 80 String (AN) Required A free-form description to clarify the related data elements and their content 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 244 285 HCP 4920 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop HCP Line Pricing Repricing Information To specify pricing or repricing information about a health care claim or line item Usage notes Required when this information is deemed necessary by the repricer. The segment is not completed by providers. The information is completed by repricers only. If not required by this implementation guide, do not send. This information is specific to the destination payer reported in Loop ID-2010BB. For capitated encounters, pricing or repricing information usually is not applicable and is provided to qualify other information within the claim. Example HCP 14 00000000 00000000000000 X 0000000 XXX 00 0 XX HP XXXXXX DA 000000000000 T6 4 4 If either Product or Service ID Qualifier (HCP-09) or Repriced Approved HCPCS Code (HCP-10) is present, then the other is required If either Unit or Basis for Measurement Code (HCP-11) or Quantity (HCP-12) is present, then the other is required Max use 1 Optional HCP-01 1473 Pricing Methodology Identifier (ID) Required Code specifying pricing methodology at which the claim or line item has been priced or repriced Usage notes Specific code use is determined by Trading Partner Agreement due to the variances in contracting policies in the industry. 00 Zero Pricing (Not Covered Under Contract) 01 Priced as Billed at 100 02 Priced at the Standard Fee Schedule 03 Priced at a Contractual Percentage 04 Bundled Pricing 05 Peer Review Pricing 06 Per Diem Pricing 07 Flat Rate Pricing 08 Combination Pricing 09 Maternity Pricing 10 Other Pricing 11 Lower of Cost 12 Ratio of Cost 13 Cost Reimbursed 14 Adjustment Pricing HCP-02 782 Monetary Amount Min 1 Max 15 Decimal number (R) Required Monetary amount 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 245 285 HCP02 is the allowed amount. HCP-03 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP03 is the savings amount. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-04 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP04 is the repricing organization identification number. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-05 118 Rate Min 1 Max 9 Decimal number (R) Optional Rate expressed in the standard monetary denomination for the currency specified HCP05 is the pricing rate associated with per diem or flat rate repricing. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-06 127 Reference Identification Min 1 Max 50 String (AN) Optional Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier HCP06 is the approved DRG code. HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_60 |
HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will contain different values from the original submitted values. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-07 782 Monetary Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount HCP07 is the approved DRG amount. Usage notes 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 246 285 This information is specific to the destination payer reported in Loop ID-2010BB. HCP-08 234 Product or Service ID Min 1 Max 48 String (AN) Optional Identifying number for a product or service HCP08 is the approved revenue code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-09 235 Product or Service ID Qualifier Identifier (ID) Optional Code identifying the type source of the descriptive number used in Product Service ID (234) ER Jurisdiction Specific Procedure and Supply Codes This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV Home Infusion EDI Coalition (HIEC) Product Service Code This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used: If a new rule names the Home Infusion EDI Coalition (HIEC) Product Service Codes as an allowable code set under HIPAA, OR The Secretary grants an exception to use the code set as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.; WK Advanced Billing Concepts (ABC) Codes At the time of this writing, this code set has been approved by the Secretary of HHS as a pilot project allowed under HIPAA law. The qualifier may only be used in transactions covered under HIPAA; By parties registered in the pilot project and their trading partners, OR If a new rule names the Complementary, Alternative, or Holistic Procedure Codes as an allowable code set under HIPAA, OR For claims which are not covered under HIPAA. HCP-10 234 Repriced Approved HCPCS Code Min 1 Max 48 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 247 285 Identifying number for a product or service HCP10 is the approved procedure code. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. HCP-11 355 Unit or Basis for Measurement Code Identifier (ID) Optional Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken DA Days UN Unit HCP-12 380 Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity HCP12 is the approved service units or inpatient days. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. HCP-13 901 Reject Reason Code Identifier (ID) Optional Code assigned by issuer to identify reason for rejection HCP13 is the rejection message returned from the third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. T1 Cannot Identify Provider as TPO (Third Party Organization) Participant T2 Cannot Identify Payer as TPO (Third Party Organization) Participant T3 Cannot Identify Insured as TPO (Third Party Organization) Participant T4 Payer Name or Identifier Missing T5 Certification Information Missing T6 Claim does not contain enough information for re-pricing HCP-14 1526 Policy Compliance Code Identifier (ID) Optional Code specifying policy compliance Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Procedure Followed (Compliance) 2 Not Followed - Call Not Made (Non-Compliance Call Not Made) 3 Not Medically Necessary (Non-Compliance Non-Medically Necessary) 4 Not Followed Other (Non-Compliance Other) 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 248 285 5 Emergency Admit to Non-Network Hospital HCP-15 1527 Exception Code Identifier (ID) Optional Code specifying the exception reason for consideration of out-of-network health care services HCP15 is the exception reason generated by a third party organization. Usage notes This information is specific to the destination payer reported in Loop ID-2010BB. 1 Non-Network Professional Provider in Network Hospital 2 Emergency Care 3 Services or Specialist not in Network 4 Out-of-Service Area 5 State Mandates 6 Other 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 249 285 2410 Drug Identification Loop Max 1 Optional LIN 4930 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop LIN Drug Identification To specify basic item identification data Usage notes Drugs and biologics reported in this segment are a further specification of service(s) described in the SV2 segment of this Service Line Loop ID-2400. Required when government regulation mandates that prescribed drugs and biologics are reported with NDC numbers. OR Required when the provider or submitter chooses to report NDC numbers to enhance the claim reporting or adjudication processes. If not required by this implementation guide, do not send. Example LIN N4 XXXX Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_61 |
enhance the claim reporting or adjudication processes. If not required by this implementation guide, do not send. Example LIN N4 XXXX Max use 1 Required LIN-02 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) LIN02 through LIN31 provide for fifteen different product service IDs for each item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., Model No., or SKU. N4 National Drug Code in 5-4-2 Format LIN-03 234 National Drug Code Min 1 Max 48 String (AN) Required Identifying number for a product or service 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 250 285 CTP 4940 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop CTP Drug Quantity To specify pricing information Example CTP 000 F2 Max use 1 Required CTP-04 380 National Drug Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity Usage notes CTP04 must be greater than 0 and less than or equal to 9,999,999.999. CTP04 is limited to up to 3 decimal positions. CTP-05 C001 Composite Unit of Measure To identify a composite unit of measure (See Figures Appendix for examples of use) Max use 1 Required C001-01 355 Code Qualifier Identifier (ID) Required Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken F2 International Unit GR Gram ME Milligram ML Milliliter UN Unit 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 251 285 2410 Drug Identification Loop end REF 4950 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Drug Identification Loop REF Prescription or Compound Drug Association Number To specify identifying information Usage notes In cases where a compound drug is being billed, the components of the compound will all have the same prescription number. Payers receiving the claim can relate all the components by matching the prescription number. Required when dispensing of the drug has been done with an assigned prescription number. OR Required when the provided medication involves the compounding of two or more drugs being reported and there is no prescription number. If not required by this implementation guide, do not send. For cases where the drug is provided without a prescription (for example, from a physician's office), the value provided in this segment is a "link sequence number". The link sequence number is a provider assigned number that is unique to this claim. Its purpose is to enable the receiver to piece together the components of the compound. Example REF VY X Max use 1 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification VY Link Sequence Number XZ Pharmacy Prescription Number REF-02 127 Prescription Number Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 252 285 2420A Operating Physician Name Loop Max 1 Optional Variants (all may be used) Other Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Operating Physician Name Loop NM1 Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when a surgical procedure code is listed on this claim. AND The Operating Physician for this line is different than the Operating Physician reported in Loop ID-2310B (claim level). If not required by this implementation guide, do not send. The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Example NM1 72 1 XX XXXXX X XXXX XX XXXX If either Identification Code Qualifier (NM1-08) or Operating Physician Primary Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 72 Operating Physician NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Operating Physician First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 253 285 Individual first name NM1-05 1037 Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Operating Physician Primary Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 254 285 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Operating Physician Name Loop REF Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_62 |
notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 1G XXXX 2U XXXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Operating Physician Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 255 285 2420A Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 256 285 2420B Other Operating Physician Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Rendering Provider Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Other Operating Physician Name Loop NM1 Other Operating Physician Name To supply the full name of an individual or organizational entity Usage notes Required when another Operating Physician is involved, AND The Other Operating Physician for this line is different than the Other Operating Physician reported in Loop ID-2310C (claim level). If not required by this implementation guide, do not send.; Example NM1 ZZ 1 X X XXXX XXXXXX XX XXXXXX If either Identification Code Qualifier (NM1-08) or Other Operating Physician Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual ZZ Mutually Defined ZZ is used to indicate Other Operating Physician. NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Other Operating Physician Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Other Operating Physician First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 257 285 Individual first name NM1-05 1037 Other Operating Physician Middle Name or Initial String (AN) Optional Min 1 Max 25 Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Other Operating Physician Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Other Operating Physician Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 258 285 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Other Operating Physician Name Loop REF Other Operating Physician Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 1G XXXXX 2U XXXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_63 |
Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Other Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 259 285 2420B Other Operating Physician Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 260 285 2420C Rendering Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Referring Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop NM1 Rendering Provider Name To supply the full name of an individual or organizational entity Usage notes Required when Rendering Provider is different than the Attending Provider reported in the 2310A loop of this claim. AND State or federal regulatory requirements call for a "combined claim", that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) AND The Rendering Provider for this line is different than the Rendering Provider reported in Loop ID 2310D (claim level). If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Example NM1 82 1 XXXXX XXXXX XXXX X XX XX If either Identification Code Qualifier (NM1-08) or Rendering Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual 82 Rendering Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Rendering Provider Last Name Min 1 Max 60 String (AN) Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 261 285 Individual last name or organizational name NM1-04 1036 Rendering Provider First Name Min 1 Max 35 String (AN) Optional Individual first name NM1-05 1037 Rendering Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Rendering Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Rendering Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 262 285 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Rendering Provider Name Loop REF Rendering Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 0B X 2U XXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. LU Location Number REF-02 127 Rendering Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 263 285 2420C Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_64 |
Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 263 285 2420C Rendering Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 264 285 2420D Referring Provider Name Loop Max 1 Optional Variants (all may be used) Operating Physician Name Loop Other Operating Physician Name Loop Rendering Provider Name Loop NM1 5000 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop NM1 Referring Provider Name To supply the full name of an individual or organizational entity Usage notes Required on an outpatient claim when the Referring Provider is different than the Attending Provider. AND The Referring Provider for this line is different than the Referring Provider reported in Loop ID 2310F (claim level). If not required by this implementation guide, do not send. The Referring Provider is provider who sends the patient to another provider for services. Example NM1 DN 1 XXX X XX XX XX XXXX If either Identification Code Qualifier (NM1-08) or Referring Provider Identifier (NM1-09) is present, then the other is required Max use 1 Required NM1-01 98 Entity Identifier Code Identifier (ID) Required Code identifying an organizational entity, a physical location, property or an individual DN Referring Provider NM1-02 1065 Entity Type Qualifier Identifier (ID) Required Code qualifying the type of entity NM102 qualifies NM103. 1 Person NM1-03 1035 Referring Provider Last Name Min 1 Max 60 String (AN) Required Individual last name or organizational name NM1-04 1036 Referring Provider First Name Min 1 Max 35 String (AN) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 265 285 Individual first name NM1-05 1037 Referring Provider Middle Name or Initial Min 1 Max 25 String (AN) Optional Individual middle name or initial Usage notes The first position must be alphabetic (A-Z). NM1-07 1039 Referring Provider Name Suffix Min 1 Max 10 String (AN) Optional Suffix to individual name NM1-08 66 Identification Code Qualifier Identifier (ID) Optional Code designating the system method of code structure used for Identification Code (67) XX Centers for Medicare and Medicaid Services National Provider Identifier NM1-09 67 Referring Provider Identifier Min 2 Max 80 String (AN) Optional Code identifying a party or other code 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 266 285 REF 5250 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Referring Provider Name Loop REF Referring Provider Secondary Identification To specify identifying information Usage notes Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the receiver to identify the provider. OR Required on or after the mandated NPI Implementation Date when NM109 in this loop is not used and an identification number other than the NPI is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send. When it is necessary to report one or more non-destination payer Secondary Identifiers, the composite data element in REF04 is used to identify the payer who assigned this identifier. Example REF 0B XX 2U XXXXX Max use 20 Optional REF-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 0B State License Number 1G Provider UPIN Number UPINs must be formatted as either X99999 or XXX999. G2 Provider Commercial Number This code designates a proprietary provider number for the destination payer identified in the Payer Name loop, Loop ID-2010BB, associated with this claim. This is to be used by all payers including: Medicare, Medicaid, Blue Cross, etc. REF-02 127 Referring Provider Secondary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier REF-04 C040 Reference Identifier To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier - REF04 contains data relating to the value cited in REF02. Usage notes Required when the identifier reported in REF02 of this segment is for a non-destination payer. Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 267 285 2420D Referring Provider Name Loop end C040-01 128 Reference Identification Qualifier Identifier (ID) Required Code qualifying the Reference Identification 2U Payer Identification Number C040-02 127 Other Payer Primary Identifier Min 1 Max 50 String (AN) Required Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Usage notes The payer identifier reported in this field must match the cooresponding payer identifier reported in Loop ID-2330B NM109. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 268 285 2430 Line Adjudication Information Loop Max 15 Optional SVD 5400 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop SVD Line Adjudication Information To convey service line adjudication information for coordination of benefits between the initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and or adjustments applied to it. If not required by this implementation guide, do not send. To | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_65 |
initial payers of a health care claim and all subsequent payers Usage notes Required when the claim has been previously adjudicated by payer identified in Loop ID-2330B and this service line has payments and or adjustments applied to it. If not required by this implementation guide, do not send. To show unbundled lines: If, in the original claim, line 3 is unbundled into (for example) 2 additional lines, then the SVD for line 3 is used 3 times: once for the original adjustment to line 3 and then two more times for the additional unbundled lines. Example SVD XX 00000000000000 HP XX XX XX XX XX XXXXXX XX X 0000 00 Max use 1 Required SVD-01 67 Other Payer Primary Identifier Min 2 Max 80 String (AN) Required Code identifying a party or other code SVD01 is the payer identification code. Usage notes This identifier indicates the payer responsible for the reimbursement described in this iteration of the 2430 loop. The identifier indicates the Other Payer by matching the appropriate Other Payer Primary Identifier (Loop ID-2330B, element NM109). SVD-02 782 Service Line Paid Amount Min 1 Max 15 Decimal number (R) Required Monetary amount SVD02 is the amount paid for this service line. Usage notes Zero "0" is an acceptable value for this element. SVD-03 C003 Composite Medical Procedure Identifier To identify a medical procedure by its standardized codes and applicable modifiers - SVD03 represents the medical procedure code upon which adjudication of this service line was based. This may be different than the submitted medical procedure code. Usage notes Required when a line level procedure code other than a revenue code was returned on the 835 remittance advice (SVC01). Max use 1 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 269 285 If not required by this implementation guide, do not send. C003-01 235 Product or Service ID Qualifier Identifier (ID) Required Code identifying the type source of the descriptive number used in Product Service ID (234) C003-01 qualifies C003-02 and C003-08. HC Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC. HP Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code C003-02 234 Procedure Code Min 1 Max 48 String (AN) Required Identifying number for a product or service If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs. C003-03 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-03 modifies the value in C003-02 and C003-08. C003-04 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-04 modifies the value in C003-02 and C003-08. C003-05 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners C003-05 modifies the value in C003-02 and C003-08. Usage notes Must be greater than zero. Must be less than or equal to 999,999.9. Must be 0 or 1 decimal position. C003-06 1339 Procedure Modifier Min 2 Max 2 String (AN) Optional This identifies special circumstances related to the performance of the service, as defined by trading partners 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 270 285 C003-06 modifies the value in C003-02 and C003-08. Usage notes Must be an integer (no decimals). C003-07 352 Procedure Code Description Min 1 Max 80 String (AN) Optional A free-form description to clarify the related data elements and their content C003-07 is the description of the procedure identified in C003-02. SVD-04 234 Service Line Revenue Code Min 1 Max 48 String (AN) Required Identifying number for a product or service SVD04 is the revenue code. SVD-05 380 Paid Service Unit Count Min 1 Max 15 Decimal number (R) Required Numeric value of quantity SVD05 is the paid units of service. Usage notes This is the number of paid units from the remittance advice. When paid units are not present on the remittance advice, use the original billed units. The maximum length for this field is 8 digits excluding the decimal. When a decimal is used, the maximum number of digits allowed to the right of the decimal is three. SVD-06 554 Bundled Line Number Min 1 Max 6 Numeric (N0) Optional Number assigned for differentiation within a transaction set SVD06 is only used for bundling of service lines. It references the LX Assigned Number of the service line into which this service line was bundled. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 271 285 CAS 5450 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop CAS Line Adjustment To supply adjustment reason codes and amounts as needed for an entire claim or for a particular service within the claim being paid Usage notes Required when the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged. If not required by this implementation guide, do not send. A single CAS segment contains six repetitions of the "adjustment trio" composed of adjustment reason code, adjustment amount, and adjustment quantity. These six adjustment trios are used to report up to six adjustments related to a particular Claim Adjustment Group Code (CAS01). The first non-zero adjustment is reported in the first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS OA X 0000 00000000000 XXXXX 0000000 00 X 0 00 000000 XX 0 000 X 00 00000 XX 000000 | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_66 |
first adjustment trio (CAS02-CAS04). If there is a second non-zero adjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19). Example CAS OA X 0000 00000000000 XXXXX 0000000 00 X 0 00 000000 XX 0 000 X 00 00000 XX 000000 00 If Adjustment Reason Code (CAS-05) is present, then at least one of Adjustment Amount (CAS-06) or Adjustment Quantity (CAS-07) is required If Adjustment Amount (CAS-06) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Quantity (CAS-07) is present, then Adjustment Reason Code (CAS-05) is required If Adjustment Reason Code (CAS-08) is present, then at least one of Adjustment Amount (CAS-09) or Adjustment Quantity (CAS-10) is required If Adjustment Amount (CAS-09) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Quantity (CAS-10) is present, then Adjustment Reason Code (CAS-08) is required If Adjustment Reason Code (CAS-11) is present, then at least one of Adjustment Amount (CAS-12) or Adjustment Quantity (CAS-13) is required If Adjustment Amount (CAS-12) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Quantity (CAS-13) is present, then Adjustment Reason Code (CAS-11) is required If Adjustment Reason Code (CAS-14) is present, then at least one of Adjustment Amount (CAS-15) or Adjustment Quantity (CAS-16) is required If Adjustment Amount (CAS-15) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Quantity (CAS-16) is present, then Adjustment Reason Code (CAS-14) is required If Adjustment Reason Code (CAS-17) is present, then at least one of Adjustment Amount (CAS-18) or Adjustment Quantity (CAS-19) is required If Adjustment Amount (CAS-18) is present, then Adjustment Reason Code (CAS-17) is required If Adjustment Quantity (CAS-19) is present, then Adjustment Reason Code (CAS-17) is required Max use 5 Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 272 285 CAS-01 1033 Claim Adjustment Group Code Identifier (ID) Required Code identifying the general category of payment adjustment CO Contractual Obligations CR Correction and Reversals OA Other adjustments PI Payor Initiated Reductions PR Patient Responsibility CAS-02 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Required Code identifying the detailed reason the adjustment was made CAS-03 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Required Monetary amount CAS03 is the amount of adjustment. CAS-04 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS04 is the units of service being adjusted. CAS-05 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-06 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS06 is the amount of the adjustment. CAS-07 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS07 is the units of service being adjusted. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 273 285 CAS-08 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-09 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS09 is the amount of the adjustment. CAS-10 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS10 is the units of service being adjusted. CAS-11 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-12 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS12 is the amount of the adjustment. CAS-13 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS13 is the units of service being adjusted. CAS-14 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-15 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 274 285 Monetary amount CAS15 is the amount of the adjustment. CAS-16 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS16 is the units of service being adjusted. CAS-17 1034 Adjustment Reason Code Min 1 Max 5 Identifier (ID) Optional Code identifying the detailed reason the adjustment was made Usage notes See CODE SOURCE 139: Claim Adjustment Reason Code CAS-18 782 Adjustment Amount Min 1 Max 15 Decimal number (R) Optional Monetary amount CAS18 is the amount of the adjustment. CAS-19 380 Adjustment Quantity Min 1 Max 15 Decimal number (R) Optional Numeric value of quantity CAS19 is the units of service being adjusted. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 275 285 DTP 5500 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop DTP Line Check or Remittance Date To specify any or all of a date, a time, or a time period Example DTP 573 D8 X Max use 1 Required DTP-01 374 Date Time Qualifier Identifier (ID) Required Code specifying type of date or time, or both date and time 573 Date Claim Paid DTP-02 1250 Date Time Period Format Qualifier Identifier (ID) Required Code indicating the date format, time format, or date and time format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times Usage | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_67 |
format DTP02 is the date or time or period format that will appear in DTP03. D8 Date Expressed in Format CCYYMMDD DTP-03 1251 Adjudication or Payment Date Min 1 Max 35 String (AN) Required Expression of a date, a time, or range of dates, times or dates and times Usage notes Must not be a future date. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 276 285 2430 Line Adjudication Information Loop end 2400 Service Line Number Loop end 2300 Claim Information Loop end 2000B Subscriber Hierarchical Level Loop end 2000A Billing Provider Hierarchical Level Loop end AMT 5505 Detail Billing Provider Hierarchical Level Loop Subscriber Hierarchical Level Loop Claim Information Loop Service Line Number Loop Line Adjudication Information Loop AMT Remaining Patient Liability To indicate the total monetary amount Usage notes In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer referenced in SVD01 of this iteration of Loop ID-2430. This segment is only used in provider submitted claims. It is not used in Payer-to-Payer Coordination of Benefits (COB). Required when the Other Payer referenced in SVD01 of this iteration of Loop ID-2430 has adjudicated this claim, provided line level information, and the provider has the ability to report line item information. If not required by this implementation guide, do not send. This segment is not used if the claim level (Loop ID-2320) Remaining Patient Liability AMT segment is used for this Other Payer. Example AMT EAF 00000000000000 Max use 1 Optional AMT-01 522 Amount Qualifier Code Identifier (ID) Required Code to qualify amount EAF Amount Owed AMT-02 782 Remaining Patient Liability Min 1 Max 15 Decimal number (R) Required Monetary amount SE 5550 Detail SE Max use 1 Required 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 277 285 Detail end Transaction Set Trailer To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments) Example SE 0 0001 SE-01 96 Transaction Segment Count Min 1 Max 10 Numeric (N0) Required Total number of segments included in a transaction set including ST and SE segments SE-02 329 Transaction Set Control Number Min 4 Max 9 Numeric (N) Required Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set Usage notes The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges. 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 278 285 GE Functional Group Trailer To indicate the end of a functional group and to provide control information Example GE 00 000000 Max use 1 Required GE-01 97 Number of Transaction Sets Included Min 1 Max 6 Numeric (N0) Required Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element GE-02 28 Group Control Number Min 1 Max 9 Numeric (N0) Required Assigned number originated and maintained by the sender 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 279 285 IEA Interchange Control Trailer To define the end of an interchange of zero or more functional groups and interchange- related control segments Example IEA 00000 000000000 Max use 1 Required IEA-01 I16 Number of Included Functional Groups Min 1 Max 5 Numeric (N0) Required A count of the number of functional groups included in an interchange IEA-02 I12 Interchange Control Number Min 9 Max 9 Numeric (N0) Required A control number assigned by the interchange sender 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 280 285 EDI Samples Example 1a: Institutional Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231031 0142 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231031 014228 000000001 X 005010X223A3 ST 837 987654 005010X223A3 BHT 0019 00 0123 19960918 0932 CH NM1 41 2 JONES HOSPITAL 46 12345 PER IC JANE DOE TE 9005555555 NM1 40 2 MEDICARE 46 00120 HL 1 20 1 PRV BI PXC 203BA0200N NM1 85 2 JONES HOSPITAL XX 9876540809 N3 225 MAIN STREET BARKLEY BUILDING N4 CENTERVILLE PA 17111 REF EI 567891234 PER IC CONNIE TE 3055551234 HL 2 1 22 0 SBR P 18 MB NM1 IL 1 DOE JOHN T MI 030005074A N3 125 CITY AVENUE N4 CENTERVILLE PA 17111 DMG D8 19261111 M NM1 PR 2 MEDICARE B PI 00435 REF G2 330127 CLM 756048Q 89.93 14 A 1 A Y Y DTP 434 RD8 19960911 CL1 3 01 HI BK 3669 HI BF 4019 BF 79431 HI BH A1 D8 19261111 BH A2 D8 19911101 BH B1 D8 19261111 BH B2 D8 19870101 HI BE A2 15.31 HI BG 09 NM1 71 1 JONES JOHN J REF 1G B99937 SBR S 01 351630 STATE TEACHERS CI OI Y Y NM1 IL 1 DOE JANE S MI 222004433 N3 125 CITY AVENUE N4 CENTERVILLE PA 17111 NM1 PR 2 STATE TEACHERS PI 1135 LX 1 SV2 0305 HC 85025 13.39 UN 1 DTP 472 D8 19960911 LX 2 SV2 0730 HC 93005 76.54 UN 3 DTP 472 D8 19960911 SE 43 987654 GE 1 000000001 IEA 1 000000001 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 281 285 Example 1b: Two Claims for the Same Provider ISA 00 00 ZZ SENDER ZZ RECEIVER 231031 0142 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231031 014255 000000001 X 005010X223A3 ST 837 987654 005010X223A3 BHT 0019 00 0123 20050630 0932 CH NM1 41 2 JONES HOSPITAL | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_68 |
health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 281 285 Example 1b: Two Claims for the Same Provider ISA 00 00 ZZ SENDER ZZ RECEIVER 231031 0142 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231031 014255 000000001 X 005010X223A3 ST 837 987654 005010X223A3 BHT 0019 00 0123 20050630 0932 CH NM1 41 2 JONES HOSPITAL 46 12345 PER IC JANE DOE TE 1112223333 NM1 40 2 TRICARE 46 99999 HL 1 20 1 PRV BI PXC 282N00000X NM1 85 2 JONES HOSPITAL XX 1234567890 N3 225 MAIN STREET N4 ANYWHERE PA 17111 REF EI 123456789 HL 2 1 22 0 SBR P 18 CH NM1 IL 1 DOE JOHN T MI 030005074 N3 125 CITY AVENUE N4 CENTERVILLE PA 17111 DMG D8 19681111 M NM1 PR 2 TRICARE PI 99999 CLM 756048Q 89.95 13 A 1 C Y Y DTP 434 RD8 20050315-20050315 CL1 1 01 HI BK 3669 HI BF 4019 BF 79431 NM1 71 1 JONES JOHN J XX 1122334455 REF 1G U12345 LX 1 SV2 0305 HC 85025 13.39 UN 1 DTP 472 D8 20050315 LX 2 SV2 0730 HC 93010 76.56 UN 3 DTP 472 D8 20050315 HL 3 1 22 0 SBR P 18 CH NM1 IL 1 SMITH JOE MI 123405074 N3 5 MAIN STREET N4 ANYWHERE PA 17111 DMG D8 19621210 M NM1 PR 2 TRICARE PI 99999 CLM 756049Q 50 13 A 1 C Y Y DTP 434 RD8 20050401-20050401 CL1 1 01 HI BK 30000 NM1 71 1 JONES JUDY J XX 9999999999 PRV AT PXC 363LP0200N LX 1 SV2 0300 HC 85087 50 UN 1 DTP 472 D8 20050401 SE 48 987654 GE 1 000000001 IEA 1 000000001 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 282 285 Example 1c: PPO Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231108 0220 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231108 022053 000000001 X 005010X223A3 ST 837 1002 005010X223A3 BHT 0019 00 1002 20050721 09460000 CH NM1 41 2 REGIONAL PPO NETWORK 46 123456789 PER IC SUBMITTER CONTACT INFO TE 8001231234 NM1 40 2 LOCAL INSURANCE COMPANY 46 54334452 HL 1 20 1 NM1 85 2 GOOD HEALTH HOSPITAL XX 1257234346 N3 592 NORTH ELM STREET N4 EDGEWOOD AZ 860015590 REF EI 344232321 HL 2 1 22 1 SBR P 46522567AW CI NM1 IL 1 JONES JENNY MI 345U8423H N3 4512 WEST AVENUE N4 EVANSVILLE AZ 863030000 DMG D8 19690731 F NM1 PR 2 LOCAL INSURANCE COMPANY PI 7452723 CLM 456DFH43 237.5 13 A 1 A Y Y DTP 434 RD8 20050706-20050706 DTP 435 DT 200507060800 CL1 1 2 01 AMT F3 237.5 REF 9A 09459034092 REF D9 04566877634343456 HI BK 38181 HI BF 38900 HI BH 11 D8 20050706 HCP 03 182.88 54.62 123456789 NM1 71 1 JOHNSON SIMON XX 5544332211 SBR S 19 T T PLUMBING COMPANY CI OI Y Y NM1 IL 1 JONES GEORGE MI 56454566 NM1 PR 2 OTHER COVERAGE COMPANY PI 534524 LX 1 SV2 0471 HC 92557 178 UN 1 DTP 472 D8 20050706 HCP 03 137.06 40.94 LX 2 SV2 0471 HC 92567 59.5 UN 1 DTP 472 D8 20050706 HCP 03 45.82 13.68 SE 42 1002 GE 1 000000001 IEA 1 000000001 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 283 285 Example 1d: Out of Network Repriced Claim ISA 00 00 ZZ SENDER ZZ RECEIVER 231031 0143 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231031 014349 000000001 X 005010X223A3 ST 837 1024 005010X223A3 BHT 0019 00 1024 20050711 1335 CH NM1 41 2 REGIONAL PPO NETWORK 46 123456789 PER IC SUBMITTER CONTACT INFO TE 8001231234 NM1 40 2 CONSERVATIVE INSURANCE 46 000110002 HL 1 20 1 NM1 85 2 LOCAL HOSPITAL XX 1122334455 N3 3423 SMALL STREET N4 COLUMBUS OH 432150000 REF EI 111002222 HL 2 1 22 0 SBR P 18 34561W CI NM1 IL 1 SMITH JAMES A MI 34902390F N3 934 NORTH STREET N4 COLUMBUS OH 432150000 DMG D8 19621015 M NM1 PR 2 CONSERVATIVE INSURANCE PI 0012 CLM W392-49141 14.84 13 A 1 A Y Y DTP 434 RD8 20050617-20050617 DTP 435 DT 200506170800 CL1 1 1 01 AMT F3 14.84 REF 9A 459804390823 REF D9 32423466233 HI BK 53081 HCP 00 0 333001234 T1 NM1 71 1 RIVERS DAWN XX 2244224455 LX 1 SV2 0301 HC 82270 14.84 UN 1 DTP 472 D8 20050617 SE 31 1024 GE 1 000000001 IEA 1 000000001 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 284 285 Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including X12, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation. Example 2a: Automobile Accident ISA 00 00 ZZ SENDER ZZ RECEIVER 231108 0222 00501 000000001 0 T GS HC SENDERGS RECEIVERGS 20231108 022219 000000001 X 005010X223A3 ST 837 557766 005010X223A3 BHT 0019 00 0324 20051111 1800 CH NM1 41 2 HALL OF FAME MEMORIAL HOSPITAL 46 737373737 PER IC KATE CASEY TE 7152569877 NM1 40 2 HEISMAN INSURANCE COMPANY 46 999888777 HL 1 20 1 PRV BI PXC 203BA0200N NM1 85 2 HALL OF FAME MEMORIAL HOSPITAL XX 2365259638 N3 1 CANTON ROAD N4 BROKEN FIELD CA 99998 REF EI 737373737 HL 2 1 22 1 SBR P AM NM1 IL 1 HOWLING HAL MI B999777791G NM1 PR 2 HEISMAN INSURANCE COMPANY PI 999888777 CLM 67236695521 545 13 A 1 A Y Y DTP 434 RD8 20051031-20051101 CL1 3 7 1 REF LU CA HI BK 8842 HI PR 8842 HI BN E9750 BN E9860 NM1 71 1 LOMBARDO VINCENT XX 2533698543 LX 1 SV2 0450 HC 98765 150 UN 1 DTP 472 | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_69 |
999888777 CLM 67236695521 545 13 A 1 A Y Y DTP 434 RD8 20051031-20051101 CL1 3 7 1 REF LU CA HI BK 8842 HI PR 8842 HI BN E9750 BN E9860 NM1 71 1 LOMBARDO VINCENT XX 2533698543 LX 1 SV2 0450 HC 98765 150 UN 1 DTP 472 D8 20051031 LX 2 SV2 0360 HC 26591 75 UN 1 DTP 472 D8 20051031 LX 3 SV2 0312 HC 86225 100 UN 2 DTP 472 D8 20051031 LX 4 SV2 0360 HC 99283 220 UN 1 DTP 472 D8 20051031 SE 36 557766 GE 1 000000001 IEA 1 000000001 1 30 25, 11:54 AM CGS Medicare 837 Health Care Claim: Institutional (X223A3) - Stedi EDI Guides https: www.stedi.com app guides view cgs-medicare health-care-claim-institutional-x223a3 01H25JDXFJR748R6M871MGNNCJ 285 285 | /kaggle/input/edi-db/CGS Medicare 837 Health Care Claim_ Institutional.pdf | 5a3f498a3f1fe3143b5bf3b242ebbf85 | 5a3f498a3f1fe3143b5bf3b242ebbf85_70 |
1 837 Companion Guide Refers to the Implementation Guides based on the HIPAA Transaction ASC X12N. Standards for Electronic Data Interchange X12N 005010x222 Health Care Claim: Professional (837P) and ASC X12N 005010x223 Health Care Claim: Institutional (837I) October 2016 2 Overview The Companion Guide provides Centene trading partners with guidelines for submitting the ASC X12N 005010x222 Health Care Claim: Professional (837P) and ASC X12N 005010x223 Health Care Claim: Institutional (837I). The Centene Companion Guide documents any assumptions, conventions, or data issues that may be specific to Centene business processes when implementing the HIPAA ASC X12N 5010A Technical Reports Type 3 (TR3). As such, this Companion Guide is unique to Centene and its affiliates. This document does NOT replace the HIPAA ASC X12N 5010A Technical Reports Type 3 (TR3) for electronic transactions, nor does it attempt to amend any of the rules therein or impose any mandates on any trading partners of Centene. This document provides information on Centene- specific code handling and situation handling that is within the parameters of the HIPAA administrative Simplification rules. Readers of this Companion Guide should be acquainted with the HIPAA Technical Reports Type 3, their structure and content. Information contained within the HIPAA TR3s has not been repeated here although the TR3s have been referenced when necessary. The HIPAA ASC X12N 5010A Technical Reports Type 3 (TR3) can be purchased at http: store.x12.org. The Companion Guide provides supplemental information to the Trading Partner Agreement (TPA) that exists between Centene and its trading partners. Refer to the TPA for guidelines pertaining to Centene legal conditions surrounding the implementations of EDI transactions and code sets. Refer to the Companion Guide for information on Centene business rules or technical requirements regarding the implementation of HIPAA compliant EDI transactions and code sets. Nothing contained in this guide is intended to amend, revoke, contradict, or otherwise alter the terms and conditions of the Trading Partner Agreement. If there is an inconsistency with the terms of this guide and the terms of the Trading Partner Agreement, the terms of the Trading Partner Agreement shall govern. Express permission to use X12 copyrighted materials within this document has been granted. Rules of Exchange The Rules of Exchange section details the responsibilities of trading partners in submitting or receiving electronic transactions with Centene. Transmission Confirmation Transmission confirmation may be received through one of two possible transactions: the ASC X12C 005010X231 Implementation Acknowledgment For Health Care Insurance (TA1, 999). A TA1 Acknowledgement is used at the ISA level of the transmission envelope structure, to confirm a positive transmission or indicate an error at the ISA level of the transmission. The 999 Acknowledgement may be used to verify a successful transmission or to indicate various types of errors. 3 Transmission Confirmation cont. Confirmations of transmissions, in the form of TA1 or 999 transactions, should be received within 24 hours of batch submissions, and usually sooner. Senders of transmissions should check for confirmations within this time frame. Batch Matching Senders of batch transmissions should note that transactions are unbundled during processing, and rebundled so that the original bundle is not replicated. Trace numbers or patient account numbers should be used for batch matching or batch balancing. TA1 Interchange Acknowledgement The TA1 Interchange Acknowledgement provides senders a positive or negative confirmation of the transmission of the ISA IEA Interchange Control. 999 Functional Acknowledgement The 999 Functional Acknowledgement reports on all Implementation Guide edits from the Functional Group and transaction Sets. 277CA Health Care Claim Acknowledgement The X12N005010X214 Health Care Claim Acknowledgment (277CA) provides a more detailed explanation of the transaction set. Centene also provides the Pre-Adjudication rejection reason of the claim within the STC12 segment of the 2220D loop. NOTE: The STC03 Action Code will only be a U if the claim failed on HIPAA validation errors, NOT Pre-Adjudication errors. Duplicate Batch Check To ensure that duplicate transmissions have not been sent, Centene checks five values within the ISA for redundancy: ISA06, ISA08, ISA09, ISA10, ISA13 Collectively, these numbers should be unique for each transmission. A duplicate ISA IEA receives a TA1 response of 025 (Duplicate Interchange Control Number). Duplicate Batch Check cont. To ensure that Transaction Sets (ST SE) have not been duplicated within a transmission, Centene checks the ST02 value (Transaction Set Control Number), which should be a unique ST02 within the Functional Group transmitted. Note: ISA08 GS03 could also be the Single Payer ID 4 New Trading Partners New trading partners should access https: www.centene.com edifecs, register for access, and perform the steps in the Centene trading partner program. The EDI Support Desk (EDIBA Centene.com) will contact you with additional steps necessary upon completing your registration. Claims Processing Acknowledgements Senders receive four types of acknowledgement transactions: the TA1 transaction to acknowledge the Interchange Control Envelope (ISA IEA) of a transaction, the 999 transaction to acknowledge the Functional Group (GS GE) and Transaction Set (ST SE), the 277CA transaction to acknowledge health care claims, and the Centene Audit Report. At the claim level of a transaction, the only acknowledgement of receipt is the return of the Claim Audit Report and or a 277CA. Coordination of Benefits (COB) Processing To ensure the proper processing of claims requiring coordination of benefits, Centene recommends that providers validate the patient s Membership Number and supplementary or primary carrier information for every claim. Code Sets Only standard codes, valid at the time of the date(s) of service, should be used. Corrections and Reversals The 837 defines what values submitters must use to signal payers that the Inbound 837 contains a reversal or correction to a claim that has previously been submitted for processing. For both Professional and Institutional 837 claims, 2300 CLM05-3 (Claim Frequency Code) must contain a value for the National UB Data Element Specification Type List Type of Bill Position 3. Data Format Content Centene accepts all compliant data elements on the 837 Professional Claim. The following points outline consistent data format and content issues that should be followed for submission. Dates The following statements apply to any dates within an 837 transaction: All dates should be formatted according to Year 2000 compliance, CCYYMMDD, except for ISA segments where the date format | /kaggle/input/edi-db/508_Centene_5010_837_Companion_Guide.pdf | 65e053b3ae1844937cfa041f22d74ce3 | 65e053b3ae1844937cfa041f22d74ce3_0 |
837 Professional Claim. The following points outline consistent data format and content issues that should be followed for submission. Dates The following statements apply to any dates within an 837 transaction: All dates should be formatted according to Year 2000 compliance, CCYYMMDD, except for ISA segments where the date format is YYMMDD. The only values acceptable for CC (century) within birthdates are 18, 19, or 20. Dates that include hours should use the following format: CCYYMMDDHHMM. Use Military format, or numbers from 0 to 23, to indicate hours. For example, an admission date of 201006262115 defines the date and time of June 26, 2010 at 9:1 5 PM. No spaces or character delimiters should be used in presenting dates or times. 5 Dates that are logically invalid (e.g. 20011301) are rejected. Dates must be valid within the context of the transaction. For example, a patient s birth date cannot be after the patient s service date. Decimals All percentages should be presented in decimal format. For example, a 12.5 value should be presented as.125. Dollar amounts should be presented with decimals to indicate portions of a dollar; however, no more than two positions should follow the decimal point. Dollar amounts containing more than two positions after the decimal point are rejected. Monetary and Unit Amount Values Centene accepts all compliant data elements on the 837 Professional Claim; however, monetary or unit amount values that are in negative numbers are rejected. Delimiters Delimiters are characters used to separate data elements within a data string. Delimiters suggested for use by Centene are specified in the Interchange Header segment (the ISA level) of a transmission; these include the tilde ( ) for segment separation, the asterisk ( ) for element separation, and the colon (:) for component separation. Phone Numbers Phone numbers should be presented as contiguous number strings, without dashes or parenthesis markers. For example, the phone number (336) 555-1212 should be presented as 3365551212. Area codes should always be included. Centene requires the phone number to be AAABBBCCCC where AAA is the Area code, BBB is the telephone number prefix, and CCCC is the telephone number. Additional Items Centene will not accept more than 97 service lines per UB-04 claim. Centene will not accept more than 50 service lines per CMS 1500 claim. Centene will only accept single digit diagnosis pointers in the SV107 of the 837P. The Value Added Network Trace Number (2300-REF02) is limited to 30 characters. 6 Identification Codes and Numbers General Identifiers Federal Tax Identifiers Any Federal Tax Identifier (Employer ID or Social Security Number) used in a transmission should omit dashes or hyphens. Centene sends and receives only numeric values for all tax identifiers. Sender Identifier The Sender Identifier is presented at the Interchange Control (ISA06) of a transmission. Centene expects to see the sender s Federal Tax Identifier (ISA05, qualifier 30) for this value. In special circumstances, Centene will accept a Mutually Defined (ZZ) value. Senders wishing to submit a ZZ value must confirm this identifier with Centene EDI. Payer Identifier Single Payer IDs are used for all Health Plans. Please verify directly with the Health Plan and or Clearinghouse the Payer ID that should be used or contact the EDI Support Desk at 800 225 2573 X6075525 or EDIBA centene.com. Plan Receiver ID Payer ID All ISA08 GS03 837P 837I NMN109 when NM101 PR Medical 68069 68069 Behavioral Health CBH 68068 68068 Centurion 42140 42140 Provider Identifiers National Provider Identifiers (NPI) HIPAA regulation mandates that providers use their NPI for electronic claims submission. The NPI is used at the record level of HIPAA transactions; for 837 claims, it is placed in the 2010AA loop. See the 837 Professional Data Element table for specific instructions about where to place the NPI within 7 the 837 Professional file. The table also clarifies what other elements must be submitted when the NPI is used. Billing provider The Billing Provider Primary Identifier should be the group organization ID of the billing entity, filed only at 2010AA. This will be a Type 2 (Group) NPI unless the Billing provider is a sole proprietor and processes all claims and remittances with a Type 1 (Individual) NPI. Rendering Provider When providers perform services for a subscriber patient, the service will need to be reported in the Rendering Provider Loop (2310B or 2420A) You should only use 2420A when it is different than Loop 2310B NM1 82. Referring Provider Centene has no specific requirements for Referring Provider information. Atypical Provider Atypical providers are not always assigned an NPI number, however, if an Atypical provider has been assigned an NPI, then they need to follow the same requirements as a medical provider. An Atypical provider which provides non-medical services is not required to have an NPI number (i.e. carpenters, transportation, etc). Existing Atypical providers need only send the Provider Tax ID in the REF segment of the billing provider loop. NOTE: If an NPI is billed in any part of the claim, it will not follow the Atypical Provider Logic. Subscriber Identifiers Submitters must use the entire identification code as it appears on the subscriber s card in the 2010BA element. Claim Identifiers Centene issues a claim identification number upon receipt of any submitted claim. The ASC X12 Technical Reports (Type 3) may refer to this number as the Internal Control Number (ICN), Document Control Number (DCN), or the Claim Control Number (CCN). It is provided to senders in the Claim Audit Report and in the CLP segment of an 835 transaction. Centene returns the submitter s Patient Account Number (2300, CLM01) on the Claims Audit Report and the 835 Claim Payment Advice (CLP01). 8 Connectivity Media for Batch Transactions Secure File Transfer Centene encourages trading partners to consider a secure File Transfer Protocol (FTP) transmission option. Centene offers two options for connectivity via FTP. Method A the trading partner will push transactions to the Centene FTP server and Centene will push outbound transactions to the Centene FTP server. Method B The Trading partner will push transactions to the Centene FTP server and Centene will push outbound transactions to the trading partner s FTP server. Encryption Centene | /kaggle/input/edi-db/508_Centene_5010_837_Companion_Guide.pdf | 65e053b3ae1844937cfa041f22d74ce3 | 65e053b3ae1844937cfa041f22d74ce3_1 |
the trading partner will push transactions to the Centene FTP server and Centene will push outbound transactions to the Centene FTP server. Method B The Trading partner will push transactions to the Centene FTP server and Centene will push outbound transactions to the trading partner s FTP server. Encryption Centene offers the following methods of encryption SSH SFTP, FTPS (Auth TLS), FTP w PGP, HTTPS (Note this method only applies with connecting to Centene s Secure FTP. Centene does not support retrieve files automatically via HTTPS from an external source at this time.) If PGP or SSH keys are used they will shared with the trading partner. These are not required for those connecting via SFTP or HTTPS. Direct Submission Centene also offers posting an 837 batch file directly on the Provider Portal website for processing. Edits and Reports Incoming claims are reviewed first for HIPAA compliance and then for Centene business rules requirements. The business rules that define these requirements are identified in the 837 Professional Data Element Table below, and are also available as a comprehensive list in the 837 Professional Claims Centene Business Edits Table. HIPAA TR3 implementation guide errors may be returned on either the TA1 or 999 while Centene business edit errors are returned on the Centene Claims Audit Report. Reporting The following table indicates which transaction or report to review for problem data found within the 837 Professional Claim Transaction. Transaction Structure Level Type of Error or Problem Transaction or Report Returned ISA IEA Interchange Control TA1 GS GE Functional Group ST SE Segment Detail Segments HIPAA Implementation Guide violations 999 Centene Claims Audit Report (a proprietary confirmation and error report) Detail Segments Centene Business Edits (see audit report rejection reason codes and explanation.) Centene Claims Audit Report (a proprietary confirmation and error report) Detail Segments HIPAA Implementation Guide violations and Centene Business Edits. 277CA 9 277CA Audit Report Rejection Codes Error Code Rejection Reason 01 Invalid Mbr DOB 02 Invalid Mbr 06 Invalid Provider 07 Invalid Mbr DOB Provider 08 Invalid Mbr Provider 09 Mbr not valid at DOS 10 Invalid Mbr DOB; Mbr not valid at DOS 12 Provider not valid at DOS 13 Invalid Mbr DOB; Prv not valid at DOS 14 Invalid Mbr; Prv not valid at DOS 15 Mbr not valid at DOS; Invalid Prv 16 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv 17 Invalid Diag Code 18 Invalid Mbr DOB; Invalid Diag 19 Invalid Mbr; Invalid Diag 21 Mbr not valid at DOS; Prv not valid at DOS 22 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS 23 Invalid Prv; Invalid Diagnosis Code 24 Invalid Mbr DOB; Invalid Prv; Invalid Diag Code 25 Invalid Mbr; Invalid Prv; Invalid Diag Code 26 Mbr not valid at DOS; Invalid Diag Code 27 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Diag Code 10 Error Code Rejection Reason 01 Invalid Mbr DOB 02 Invalid Mbr 06 Invalid Provider 07 Invalid Mbr DOB Provider 29 Provider not valid at DOS; Invalid Diag Code 30 Invalid Mbr DOB; Prv not valid at DOS; Invalid Diag 31 Invalid Mbr; Prv not valid at DOS; Invalid Diag 32 Mbr not valid at DOS; Prv not valid; Invalid Diag 33 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv; Invalid Diag 34 Invalid Proc 35 Invalid Mbr DOB; Invalid Proc 36 Invalid Mbr; Invalid Proc 37 Invalid Future Service Date 38 Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 39 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 40 Invalid Prv; Invalid Proc 41 Invalid Mbr DOB, Invalid Prv; Invalid Proc 42 Invalid Mbr; Invalid Prv; Invalid Proc 43 Mbr not valid at DOS; Invalid Proc 44 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Proc 46 Prv not valid at DOS; Invalid Proc 48 Invalid Mbr; Prv not valid at DOS; Invalid Proc 49 Mbr not valid at DOS; Invalid Prv; Invalid Proc 51 Invalid Diag; Invalid Proc 11 Error Code Rejection Reason 01 Invalid Mbr DOB 02 Invalid Mbr 06 Invalid Provider 07 Invalid Mbr DOB Provider 52 Invalid Mbr DOB; Invalid Diag; Invalid Proc 53 Invalid Mbr; Invalid Diag; Invalid Proc 55 Mbr not valid at DOS; Prv not valid at DOS; Invalid Proc 57 Invalid Prv; Invalid Diag; Invalid Proc 58 Invalid Mbr DOB; Invalid Prv; Invalid Diag; Invalid Proc 59 Invalid Mbr; Invalid Prv; Invalid Diag; Invalid Proc 60 Mbr not valid at DOS;Invalid Diag;Invalid Proc 61 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Diag; Invalid Proc 63 Prv not valid at DOS; Invalid Diag; Invalid Proc 64 Invalid Mbr DOB; Prv not valid at DOS; Invalid Diag; Invalid Proc 65 Invalid Mbr; Prv not valid at DOS; Invalid Diag; Invalid Proc 66 Mbr not valid at DOS; Invalid Prv; Invalid Diag; Invalid Proc 67 Invalid Mbr DOB; Mbr not valid at DOS; Invalid Prv; Invalid Diag; Invalid Proc 72 Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag; Invalid Proc 73 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag; Invalid Proc 74 Services performed prior to Contract Effective Date 75 Invalid units of service 76 Original Claim Number Required 77 Invalid Claim Type 78 Diagnosis Pointer- Not in sequence or incorrect length 12 Error Code Rejection Reason 01 Invalid Mbr DOB 02 Invalid Mbr 06 Invalid Provider 07 Invalid Mbr DOB Provider 81 Invalid units of service, Invalid Prv 83 Invalid units of service, Invalid Prv, Invalid Mbr 89 Invalid Mbr DOB; Mbr not valid at DOS; Prv not valid at DOS; Invalid Diag 91 Invalid Missing Taxonomy or NPI Invalid Prov 92 Invalid Referring Ordering NPI 93 Mbr not valid at DOS; Invalid Proc 96 GA OPR NPI Registration-State A2 Diagnosis Pointer Invalid A3 Service Lines- Greater than 97 Service lines submitted- Invalid B1 Rendering and Billing NPI are not tied on State File- IN rejection B2 Not enrolled with MHS IN and or State with rendering NPI TIN on DOS. Enroll with MHS and Resubmit claim B5 Invalid | /kaggle/input/edi-db/508_Centene_5010_837_Companion_Guide.pdf | 65e053b3ae1844937cfa041f22d74ce3 | 65e053b3ae1844937cfa041f22d74ce3_2 |
A2 Diagnosis Pointer Invalid A3 Service Lines- Greater than 97 Service lines submitted- Invalid B1 Rendering and Billing NPI are not tied on State File- IN rejection B2 Not enrolled with MHS IN and or State with rendering NPI TIN on DOS. Enroll with MHS and Resubmit claim B5 Invalid CLIA C7 NPI Registration- State GA OPR C9 Invalid Missing Attending NPI HP H1 H2 ICD9 after end date ICD10 sent before Eff Date Mixed ICD versions | /kaggle/input/edi-db/508_Centene_5010_837_Companion_Guide.pdf | 65e053b3ae1844937cfa041f22d74ce3 | 65e053b3ae1844937cfa041f22d74ce3_3 |
and TR3 specific information. That information may contain: o o o o o Limits on the repeat of loops or segments Limits on the length of a simple data element Specifics on a sub-set of the Implementation Guide s (IG) s internal code listings Clarification of the use of loops, segments, and composite or simple data elements Any other information tied directly to a loop, segment, and composite or simple data element pertinent to trading electronically with CMS. In addition to the row for each segment, one (1) or more additional rows are used to describe the EDS usage for composite or simple data elements and for any other information. 1.3 Major Updates 1.3.1 EDFES Notifications MAOs and other entities may reference Section 6.7, Table 10 for new EDFES notifications. 1.3.2 EDIPPS Edits and EDIPPS Edits Enhancements Implementation Updates MAOs and other entities may reference Section 10.0, Table 14 and Section 10.1, Table 15 for new edits in the EDIPPS. 837 Institutional Companion Guide Version 38.0 July 2016. 8 1.3.3 EDIPPS Edits Prevention and Resolution Strategies Scenarios Updates MAOs may reference Section 10.2.3, Table 18 for new and updated Prevention and Resolution Strategies and scenarios for EDIPPS edits. MAOs and other entities must use the ASC X12N TR3 adopted under the HIPAA Administrative Simplification Electronic Transaction rule, along with CMS EDS Companion Guides, for development of the EDS transactions. These documents are accessible on the CSSC Operations website at http: www.csscoperations.com. Additionally, CMS publishes the EDS submitter guidelines and application, testing documents, and 837 EDS Companion Guides on the CSSC Operations website. 1.4 References MAOs and other entities must use the most current national standard code lists applicable to the 5010 transaction. The code lists is accessible at the Washington Publishing Company (WPC) website at: http: www.wpc-edi.com. The applicable code lists are as follows: Claim Adjustment Reason Code (CARC) Claim Status Category Codes (CSCC) Claim Status Codes (CSC) CMS provides X12 5010 file format technical edit spreadsheets (CMS 5010 Edits Spreadsheets) for the 837-I, 837-P, and 837-DME modules. The edits included in the spreadsheets are provided to clarify the WPC instructions or add Medicare specific requirements. In order to determine the implementation date of the edits contained in the spreadsheet, MAOs and other entities should initially refer to the spreadsheet version identifier. The version identifier is comprised of ten (10) characters, as follows: Positions 1-2 indicate the line of business: o o o EA Part A (837-I) EB Part B (837-P) CE DME Part B Drugs Positions 3-6 indicate the year (e.g., 2015) Position 7 indicates the release quarter month o o o o 1 January release 2 April release 3 July release 4 October release Positions 8-10 indicate the spreadsheet version iteration number (e.g., V01-first iteration, V02- second iteration) The effective date of the spreadsheet is the first calendar day of the release quarter month. The implementation date is the first business Monday of the release quarter month. Federal holidays that potentially occur on the first business Monday are considered when determining the implementation date. 837 Institutional Companion Guide Version 38.0 July 2016. 9 2.0 Contact Information 2.1 The Customer Service and Support Center (CSSC) The Customer Service and Support Center (CSSC) personnel are available for questions from 8:00 AM 7:00PM ET, Monday-Friday, with the exception of federal holidays. MAOs and other entities are able to contact the CSSC by phone at 1-877-534-CSSC (2772) or by email at csscoperations palmettogba.com. 2.2 Applicable Websites Email Resources The following websites provide information to assist in the EDS submission: EDS WEBSITE RESOURCES RESOURCE WEB ADDRESS EDS Inbox encounterdata cms.hhs.gov EDS Participant Guide http: www.csscoperations.com EDS User Group and Webinar Materials http: www.csscoperations.com ANSI ASC X12 TR3 http: www.wpc-edi.com Washington Publishing Company Health Care Code Sets http: www.wpc-edi.com CMS 5010 Edits Spreadsheets https: www.cms.gov Regulations-and-Guidance Guidance Transmittals 3.0 File Submission 3.1 File Size Limitations Due to system limitations, ISA IEA transaction sets should not exceed 5,000 encounters. Also, it is highly recommended that MAOs and other entities submit larger numbers of encounters within each ST SE transaction set, not to exceed 5,000 encounters. In an effort to support and provide the most efficient processing system, and to allow for maximum performance, CMS recommends that FTP submitters scripts upload no more than one (1) file per five (5) minute intervals. Zipped files should contain one (1) file per transmission. NDM and Gentran TIBCO users may submit a maximum of 255 files per day. These submission practices will assist with prevention of delays in the generation and distribution of EDFES Acknowledgement reports. Note: Due to system processing overhead associated with smaller numbers of encounters within the ST SE, it is highly recommended that MAOs and other entities submit larger numbers of encounters within the ST SE, not to exceed 5,000 encounters. In an effort to support and provide the most efficient processing system, and to allow for maximum performance, CMS recommends that FTP submitters scripts upload no more than one (1) file per five (5) minute intervals. Zipped files should contain one (1) file per transmission. MAOs and other entities 837 Institutional Companion Guide Version 38.0 July 2016. 10 should refrain from submitting multiple files within the same transmission. NDM and Gentran TIBCO users may submit a maximum of 255 files per day. 3.2 File Structure NDM Connect Direct and Gentran TIBCO Submitters Only NDM Connect Direct and Gentran TIBCO submitters must format all submitted files in an 80-byte fixed block format. This means MAOs and other entities must upload every line (record) in a file with a length of 80 bytes characters. Submitters should create files with segments stacked, using only 80 characters per line. At position 81 of each segment, MAOs and other entities must create a new line. On the new line starting in position 1, continue for 80 characters, and repeat creating a new line in position 81 until the file is complete. If the last line in the file does not fill to 80 characters, the submitter should space the line out to position 80 and then save the file. Note: If MAOs and other entities are using a text editor to create the | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_0 |
in position 81 until the file is complete. If the last line in the file does not fill to 80 characters, the submitter should space the line out to position 80 and then save the file. Note: If MAOs and other entities are using a text editor to create the file, pressing the Enter key will create a new line. If MAOs and other entities are using an automated system to create the file, create a new line by using a CRLF (Carriage Return Line Feed) or a LF (Line Feed). For example, the ISA record is 106 characters long: The first line of the file will contain the first 80 characters of the ISA segment; the last 26 characters of the ISA segment continue on the second line. The next segment will start in the 27th position and continue until column 80. ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: Note to NDM Connect:Direct Users: If a submitter has not established a sufficient number of Generated Data Groups (GDGs) to accommodate the number of files returned from the EDFES, not all of the EDFES Acknowledgement reports will be stored in the submitter s system. To prevent this situation, NDM Connect:Direct submitters should establish a limit of 255 GDGs in their internal processing systems. 4.0 Control Segments Envelopes 4.1 ISA IEA The term interchange denotes the transmitted ISA IEA envelope. Interchange control is achieved through several control components, as defined in Table 1. The interchange control number is contained in data element ISA13 of the ISA segment. The identical control number must also occur in data element IEA02 of the IEA segment. MAOs and other entities must populate all elements in the ISA IEA interchange. There are several elements within the ISA IEA interchange that must be populated specifically for encounter data purposes. Table 1 below provides EDS Interchange Control (ISA IEA) specific elements. Note: Table 1 presents only those elements that provide specific details relevant to encounter data. When developing the encounter data system, users should base their logic on the highest level of specificity. First, consult the WPC TR3. Second, consult the CMS 5010 Edits Spreadsheets. Third, 837 Institutional Companion Guide Version 38.0 July 2016. 11 consult the CMS EDS 837-I Companion Guide. If there are options expressed in the WPC TR3 or the CMS 5010 Edits Spreadsheets that are broader than the options identified in the CMS EDS 837-I Companion Guide, MAOs and other entities must use the rules identified in the Companion Guide. LEGEND TO TABLE 1 Legend SHADED rows represent segments in the X12N TR3 NON-SHADED rows represent data elements in the X12N TR3 TABLE 1 ISA IEA INTERCHANGE ELEMENTS LOOP ID REFERENCE NAME CODES NOTES COMMENTS ISA N A Interchange Control Header N A N A ISA ISA01 Authorization Information Qualifier 00 No authorization information present LOOP ID REFERENCE NAME CODES NOTES COMMENTS ISA ISA02 Authorization Information N A Use 10 blank spaces ISA ISA03 Security Information Qualifier 00 No security information present ISA ISA04 Security Information N A Use 10 blank spaces ISA ISA05 Interchange ID Qualifier ZZ CMS expects to see a value of ZZ to designate that the code is mutually defined ISA ISA06 Interchange Sender ID N A EN followed by Contract ID Number ISA ISA08 Interchange Receiver ID 80881 N A ISA ISA11 Repetition Separator N A ISA ISA13 Interchange Control Number N A Must be fixed length with nine (9) characters and match IEA02 Used to identify file level duplicate collectively with GS06, ST02, and BHT03 ISA ISA14 Acknowledgement Requested 1 A TA1 will be sent if the file is syntactically incorrect, otherwise only a 999 will be sent ISA ISA15 Usage Indicator T P Test Production IEA N A Interchange Control Trailer N A N A IEA IEA02 Interchange Control Number N A Must match the value in ISA13 837 Institutional Companion Guide Version 38.0 July 2016. 12 4.2 GS GE The functional group is outlined by the functional group header (GS segment) and the functional group trailer (GE segment). The functional group header starts and identifies one or more related transaction sets and provides a control number and application identification information. The functional group trailer defines the end of the functional group of related transaction sets and provides a count of contained transaction sets. MAOs and other entities must populate all elements in the GS GE functional group. There are several elements within the GS GE that must be populated specifically for encounter data collection. Table 2 provides EDS functional group (GS GE) specific elements. Note: Table 2 presents only those elements that require explanation. TABLE 2 GS GE FUNCTIONAL GROUP ELEMENTS LOOP ID REFERENCE NAME CODES NOTES COMMENTS GS N A Functional Group Header N A N A GS GS02 Application Sender s Code N A EN followed by Contract ID Number This value must match the value in the ISA06 GS GS03 Application Receiver s Code 80881 This value must match the value in ISA08 GS GS06 Group Control Number N A This value must match the value in GE02 Used to identify file level duplicates collectively with ISA13, ST02, and BHT03 GS GS08 Version Release Industry Identifier Code 005010X223A2 N A GE N A Functional Group Trailer N A N A GE GE02 Group Control Number N A This value must match the value in GS06 837 Institutional Companion Guide Version 38.0 July 2016. 13 4.3 ST SE The transaction set (ST SE) contains required, situational loops, unused loops, segments, and data elements. The transaction set is outlined by the transaction set header (ST segment) and the transaction set trailer (SE segment). The transaction set header identifies the start and identifies the transaction set. The transaction set trailer identifies the end of the transaction set and provides a count of the data segments, which includes the ST and SE segments. Several elements must be populated specifically for encounter data purposes. Table 3 provides EDS transaction set (ST SE) specific elements. Note: Table 3 presents only those elements that require explanation. TABLE 3 ST SE TRANSACTION SET HEADER AND TRAILER ELEMENTS LOOP | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_1 |
data segments, which includes the ST and SE segments. Several elements must be populated specifically for encounter data purposes. Table 3 provides EDS transaction set (ST SE) specific elements. Note: Table 3 presents only those elements that require explanation. TABLE 3 ST SE TRANSACTION SET HEADER AND TRAILER ELEMENTS LOOP ID REFERENCE NAME CODES NOTES COMMENTS ST N A Transaction Set Header N A N A ST ST01 Transaction Set Identifier Code 837 N A ST ST02 Transaction Set Control Number N A This value must match the value in SE02 Used to identify file level duplicates collectively with ISA13, GS06, and BHT03 ST ST03 Implementation Convention Reference 005010X223A2 N A SE N A Transaction Set Trailer N A N A SE SE01 Number of Included Segments N A Must contain the actual number of segments within the ST SE SE SE02 Transaction Set Control Number N A This value must be match the value in ST02 5.0 Transaction Specific Information 5.1 837 Institutional: Data Element Table Within the ST SE transaction set, there are multiple loops, segments, and data elements that provide billing provider, subscriber, and patient level information. MAOs and other entities should reference www.wpc-edi.com to obtain the most current TR3. MAOs and other entities must submit EDS transactions using the most current transaction version. The 837 Institutional Data Element table identifies only those elements within the X12N TR3 that require comment within the context of the EDS submission. Table 4 identifies the 837 Institutional TR3 by loop name, segment name, segment identifier, data element name, and data element identifier for cross reference. Not all data elements listed in the table below are required, but if they are used, the table reflects the values CMS expects to see. 837 Institutional Companion Guide Version 38.0 July 2016. 14 TABLE 4 837 INSTITUTIONAL HEALTH CARE CLAIM LOOP ID REFERENCE NAME CODES NOTES COMMENTS N A BHT Beginning of Hierarchical Transaction N A N A N A BHT03 Originator Application Transaction Identifier N A Must be a unique identifier across all files Used to identify file level duplicates collectively with ISA13, GS06, and ST02. N A BHT06 Claim Identifier CH Chargeable 1000A NM1 Submitter Name N A N A 1000A NM102 Entity Type Qualifier 2 Non-Person Entity 1000A NM109 Submitter Identifier N A EN followed by Contract ID Number 1000A PER Submitter EDI Contact Info N A N A 1000A PER03 Communication Number Qualifier TE It is recommended that MAOs and other entities populate the submitter s telephone number 1000A PER05 Communication Number Qualifier EM It is recommended that MAOs and other entities populate the submitter s email address 1000A PER Submitter EDI Contact Information N A N A 1000A PER07 Communication Number Qualifier FX It is recommended that MAOs and other entities populate the submitter s fax number 1000B NM1 Receiver Name N A N A 1000B NM102 Entity Type Qualifier 2 Non-Person Entity 1000B NM103 Receiver Name N A EDSCMS 1000B NM109 Receiver ID 80881 Identifies CMS as the receiver of the transaction and corresponds to the value in ISA08 Interchange Receiver ID. When the Payer ID must be changed for an encounter submitted to the EDS, MAOs and other entities must first void the original encounter, then submit a new encounter with the correct Payer ID.A 2010AA NM1 Billing Provider Name N A N A 2010AA NM108 Billing Provider ID Qualifier XX NPI Identifier 2010AA NM109 Billing Provider Identifier 1XXXXXXXXX Must be populated with a ten digit number, must begin with 1 Note: Default NPIs should only be submitted to the EDS when the 837 Institutional Companion Guide Version 38.0 July 2016. 15 LOOP ID REFERENCE NAME CODES NOTES COMMENTS provider is considered to be atypical. Institutional Default NPI: 1999999976 2010AA N4 Billing Provider City, State, Zip Code N A N A 2010AA N403 Zip Code N A The full nine (9) digits of the ZIP Code are required. If the last four (4) digits of the ZIP code are not available, populate a default value of 9998. 2010AA REF Billing Provider Tax Identification Number N A N A 2010AA REF01 Reference Identification Qualifier EI Employer s Identification Number (EIN) 2010AA REF02 Billing Provider Tax Identification Number XXXXXXXXX Must be populated with XXXXXXXXX. Note: Default EINs should only be submitted to the EDS when the provider is considered atypical. Institutional Default EIN: 199999997 2000B SBR Subscriber Information N A N A 2000B SBR01 Payer Responsibility Number Code S EDSCMS is considered the destination (secondary) payer 2000B SBR09 Claim Filing Indicator Code MA Must be populated with a value of MA Medicare Part A 2010BA NM1 Subscriber Name N A N A 2010BA NM108 Subscriber Id Qualifier MI Must be populated with a value of MI Member Identification Number 2010BA NM109 Subscriber Primary Identifier N A This is the subscriber s Health Insurance Claim (HIC) number. Must match the value in Loop 2330A, NM109 2010BB NM1 Payer Name N A N A 2010BB NM103 Payer Name N A EDSCMS 2010BB NM108 Payer ID Qualifier PI Must be populated with the value of PI Payer Identification 2010BB NM109 Payer Identification 80881 When the Payer ID must be changed for an encounter submitted to the EDS, MAOs and other entities must first void the original encounter, then submit a new encounter with the correct Payer ID. 2010BB N3 Payer Address N A N A 2010BB N301 Payer Address Line 7500 Security Blvd N A 837 Institutional Companion Guide Version 38.0 July 2016. 16 LOOP ID REFERENCE NAME CODES NOTES COMMENTS 2010BB N4 Payer City, State, ZIP Code N A N A 2010BB N401 Payer City Name Baltimore N A 2010BB N402 Payer State MD N A 2010BB N403 Payer ZIP Code 212441850 N A 2010BB REF Other Payer Secondary Identifier N A N A 2010BB REF01 Contract ID Identifier 2U N A 2010BB REF02 Contract ID Number N A MAO or other entities Contract ID Number 2300 CLM Claim Information N A N A 2300 CLM02 Total Claim Charge Amount N A N A 2300 CLM05-3 Claim Frequency Type Code 1 2 3 4 7 8 9 1 Original claim submission 2 Interim First Claim | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_2 |
ID Number N A MAO or other entities Contract ID Number 2300 CLM Claim Information N A N A 2300 CLM02 Total Claim Charge Amount N A N A 2300 CLM05-3 Claim Frequency Type Code 1 2 3 4 7 8 9 1 Original claim submission 2 Interim First Claim 3 Interim Continuing Claim 4 Interim Last Claim 7 Replacement 8 Void 9 Final Claim for a Home Health PPS Episode 2300 DTP Date Admission Date Hour N A N A 2300 DTP02 Date Time Period Format Qualifier D8 DT D8 CCYYMMDD DT CCYYMMDDHHMM 2300 DTP03 Admission Date Hour N A Hours (HH) are expressed as 00 for midnight, 01 for 1A.M., and so on through 23 for 11P.M. Minutes (MM) are expressed as 00 through 59. If the actual minutes are not known, use a default of 00. This is only required for original or final bills 2300 PWK Claim Supplemental Info N A N A 2300 PWK01 Report Type Code 09 OZ PY Populated for chart review submissions only Populated for encounters generated as a result of paper claims only Populated for encounters generated as a result of 4010 submission only 2300 PWK02 Attachment Transmission Code AA Populated for chart review, paper generated, and 4010 generated encounters 2300 CN1 Contract Information N A N A 2300 CN101 Contract Type Code 05 Populated for capitated staff model arrangements 2300 REF Payer Claim Control Number N A N A 2300 REF01 Original Reference Number F8 N A 837 Institutional Companion Guide Version 38.0 July 2016. 17 LOOP ID REFERENCE NAME CODES NOTES COMMENTS 2300 REF02 Payer Claim Control Number N A Identifies ICN from original encounter when submitting void or replacement EDR or chart review data EDR 2300 REF Medical Record Number N A N A 2300 REF01 Medical Record Identification Number EA N A 2300 REF02 Medical Record Identification Number 8 Chart review delete diagnosis code only submission Identifies the diagnosis code populated in Loop 2300, HI must be deleted from the encounter ICN in Loop 2300, REF02. 2300 NTE Claim Note N A N A 2300 NTE01 Note Reference Code ADD N A 2300 NTE02 Claim Note Text N A See Section 11.0 for the use and message requirements of default data information 2300 HI Value Information N A N A 2300 HI01-2 Value Code A0 Required on all ambulance encounters 2300 HI01-5 Value Code Amount N A If available, the ambulance pick-up location ZIP Code 4 should be provided. The ZIP code must be in the following format: XXXXXXX.XX (If a valid 4 cannot be populated, use 9998 as the 4 extension (XXXXX99.98)). 2320 SBR Other Subscriber Information N A N A 2320 SBR01 Payer Responsibility Sequence Number Code P T P Primary (when MAOs or other entities populate the payer paid amount) T Tertiary (when MAOs or other entities populate a true COB) 2320 SBR09 Claim Filing Indicator Code 16 Health Maintenance Organization (HMO) Medicare Risk 2330A NM1 Other Subscriber Name N A N A 2330A NM108 Identification Code Qualifier MI N A 2330A NM109 Subscriber Primary Identifier N A Must match the value in Loop 2010BA, NM109 2330B NM1 Other Payer Name N A N A 2330B NM108 Identification Code Qualifier XV N A 2330B NM109 Other Payer Primary Identifier Payer 01 MAO or other entity s Contract ID Number. Only populated if there is no Contract ID Number available for a true other payer 837 Institutional Companion Guide Version 38.0 July 2016. 18 LOOP ID REFERENCE NAME CODES NOTES COMMENTS 2330B N3 Other Payer Address N A N A 2330B N301 Other Payer Address Line N A MAO or other entity s address 2330B N4 Other Payer City, State, ZIP Code N A N A 2330B N401 Other Payer City Name N A MAO or other entity s City Name 2330B N402 Other Payer State N A MAO or other entity s State 2330B N403 Other Payer ZIP Code N A MAO or other entity s ZIP Code 2430 SVD Line Adjudication Information N A N A 2430 SVD01 Other Payer Primary Identifier N A Must match the value in Loop 2330B, NM109 2430 CAS Line Adjustments N A N A 2430 CAS02 Adjustment Reason Code N A If a service line is denied in the MAO s or other entity s adjudication system, the denial reason must be populated 2430 DTP Line Check or Remittance Date N A N A 2430 DTP03 N A N A Populate the claim receipt date minus one (1) day as the default primary payer adjudication date only in the instance that the primary payer adjudication date is not available 6.0 Acknowledgements and or Reports 6.1 TA1 Interchange Acknowledgement The TA1 report enables the receiver to notify the sender when there are problems with the interchange control structure. As the interchange envelope enters the EDFES, the EDI translator performs TA1 validation of the control segments envelope. The sender will only receive a TA1 there are syntax errors in the file. Errors found in this stage will cause the entire X12 interchange to be rejected with no further processing. MAOs and other entities will receive a TA1 interchange report acknowledging the syntactical inaccuracy of an X12 interchange header ISA and trailer IEA and the envelope s structure. Encompassed in the TA1 is the interchange control number, interchange date and time, interchange acknowledgement code, and interchange note code. The interchange control number, date, and time are identical to those populated on the original 837-I or 837-P ISA line, which allows for MAOs and other entities to associate the TA1 with a specific file previously submitted. Within the TA1 segment, MAOs and other entities will be able to determine if the interchange rejected by examining the interchange acknowledgement code (TA104) and the interchange note code (TA105). The interchange acknowledgement code stipulates whether the interchange (ISA IEA) rejected due to syntactical errors. An R will be the value in the TA104 data element if the interchange rejected due to syntactical errors. The interchange note code is a numeric code that notifies MAOs and other entities of the specific error. If a fatal error occurs, the EDFES | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_3 |
IEA) rejected due to syntactical errors. An R will be the value in the TA104 data element if the interchange rejected due to syntactical errors. The interchange note code is a numeric code that notifies MAOs and other entities of the specific error. If a fatal error occurs, the EDFES generates and returns the TA1 interchange acknowledgement report within 24 hours of the interchange submission. If a TA1 interchange control 837 Institutional Companion Guide Version 38.0 July 2016. 19 structure error is identified, MAOs and other entities must correct the error and resubmit the interchange file. 6.2 999 Functional Group Acknowledgement After the interchange passes the TA1 edits, the next stage of editing is to apply Common Edits and Enhancements Module (CEM) edits and verify the syntactical accuracy of the functional group(s) (GS GE). Functional groups allow for organization of like data within an interchange; therefore, more than one (1) functional group containing multiple claims within the functional group can be populated in a file. The 999 acknowledgement report provides information on the validation of the GS GE functional group(s) and the consistency of the data. The 999 report provides MAOs and other entities information on whether the functional groups were accepted or rejected. If a file has multiple GS GE segments and errors occurred at any point within one (1) of the syntactical and IG level edit validations, the GS GE segment will reject, and processing will continue to the next GS GE segment. For instance, if a file is submitted with three (3) functional groups and there are errors in the second functional, the first functional group will accept, the second functional group will reject, and processing will continue to the third functional group. The 999 transaction set is designed to report on adherence to IG level edits and CMS standard syntax errors as depicted in the CMS 5010 Edits Spreadsheets. Three (3) possible acknowledgement values are: A Accepted R Rejected P Partially Accepted, At Least One (1) Transaction Set Was Rejected When viewing the 999 report, MAOs and other entities should navigate to the IK5 and AK9 segments. If an A is displayed in the IK5 and AK9 segments, the claim file is accepted and will continue processing. If an R is displayed in the IK5 and AK9 segments, an IK3 and an IK4 segment will be displayed. These segments indicate what loops and segments contain the error that requires correction so the interchange can be resubmitted. The third element in the IK3 segment identifies the loop that contains the error. The first element in the IK3 and IK4 indicates the segment and element that contain the error. The third element in the IK4 segment indicates the reason code for the error. 6.3 277CA Claim Acknowledgement After the file is accepted at the interchange and functional group levels, the third level of editing occurs at the transaction set level within the CEM in order to create the Claim Acknowledgement Transaction (277CA) report. The CEM checks the validity of the values within the data elements. For instance, data element N403 must be a valid nine (9)-digit ZIP code. If a non-existent ZIP code is populated, the CEM will reject the encounter. The 277CA is an unsolicited acknowledgement report from CMS to MAOs and other entities. The 277CA is used to acknowledge the acceptance or rejection of encounters submitted using a hierarchical level (HL) structure. The first level of hierarchical editing is at the Information Source level. This entity is the decision maker in the business transaction receiving the X12 837 transactions (EDSCMS). The next level is at the Information Receiver level. This is the entity expecting the response from the Information Source. The third hierarchal level is at the Billing Provider of Service level; and the fourth and final level is done at the Patient level. Acceptance or rejection at this level is based on the WPC and the CMS 5010 Edits Spreadsheets. Edits received at any hierarchical level will stop and no further editing will take place. For example, if there is a problem with the Billing Provider of Service 837 Institutional Companion Guide Version 38.0 July 2016. 20 submitted on the 837, individual patient edits will not be performed. For those encounters not accepted, the 277CA will detail additional actions required of MAOs and other entities in order to correct and resubmit those encounters. If an MAO or other entity receives a 277CA indicating that an encounter was rejected, the MAO or other entity must resubmit the encounter until the 277CA indicates no errors were found. If an encounter is accepted, the 277CA will provide the ICN assigned to that encounter. The ICN segment for the accepted encounter will be located in 2200D REF segment, REF01 IK and REF02 ICN. The ICN is a unique 13-digit number. If an encounter rejects, the 277CA will provide edit information in the STC segment. The STC03 data element will convey whether the HL structures accepted or rejected. The STC03 is populated with a value of WQ if the HL was accepted. If the STC03 data element is populated with a value of U, the HL is rejected and the STC01 data element will list the acknowledgement code. 6.4 MAO-001 Encounter Data Duplicates Report When the MAO-002 Encounter Data Processing Status Report is returned to an MAO or other entity, and contains one or more the following edits, 98300 Exact Inpatient Duplicate Encounter, 98315 Linked Chart Review Duplicate, 98320 Chart Review Duplicate, or 98325 Service Line(s) Duplicated, the EDPS will also generate and return the MAO-001 Encounter Data Duplicates Report. MAOs and other entities will not receive the MAO-001 report if there are no duplicate errors received on submitted encounters. The MAO-001 report is a fixed length report available in flat file and formatted report layouts. It provides information for encounters and service lines that receive a status of reject and specific error messages 98300, 98315, 98320, or 98325. MAOs and other entities must correct and resubmit only those encounters that received edits 98300, 98315, 98320, or 98325. The MAO-001 report allows MAOs and other entities the opportunity to more easily reconcile these duplicate | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_4 |
that receive a status of reject and specific error messages 98300, 98315, 98320, or 98325. MAOs and other entities must correct and resubmit only those encounters that received edits 98300, 98315, 98320, or 98325. The MAO-001 report allows MAOs and other entities the opportunity to more easily reconcile these duplicate encounters and service lines. 6.5 MAO-002 Encounter Data Processing Status Report After a file accepts through the EDFES, the file is transmitted to the Encounter Data Processing System (EDPS) where further editing, processing, pricing, and storage occurs. As a result of EDPS editing, the EDPS will return the MAO-002 Encounter Data Processing Status Report. The MAO-002 report is a fixed length report available in flat file and formatted report layouts that provide encounter and service line level information. The MAO-002 reflects two (2) statuses at the encounter and service line level: accepted or rejected. Lines that reflect a status of accept yet contain an error message in the Error Description column are considered informational edits. MAOs and other entities are not required to take further action on informational edits; however, they are encouraged to do so to ensure accuracy of internal claims processing data. The 000 line on the MAO-002 report identifies the header level and indicates either accepted or rejected status. If the 000 header line is rejected, the encounter is considered rejected and MAOs 837 Institutional Companion Guide Version 38.0 July 2016. 21 and other entities must correct and resubmit the encounter. If the 000 header line is accepted and at least one (1) other line (i.e., 001 002 003 004) is accepted, then the overall encounter is accepted. 6.6 Reports File Naming Conventions In order for MAOs and other entities to receive and identify the EDFES Acknowledgement Reports (TA1, 999 and 277CA) and EDPS MAO-002 Encounter Data Processing Status Reports, specific reports file naming conventions have been used. The file name ensures that the specific reports are appropriately distributed to each secure, unique mailbox. The EDFES and EDPS have established unique file naming conventions for reports distributed during testing and production. 6.6.1 Testing Reports File Naming Convention Table 5 below provides the EDFES reports file naming conventions according to connectivity method. MAOs and other entities should note that Connect:Direct (NDM) users reports file naming conventions are user defined. 837 Institutional Companion Guide Version 38.0 July 2016. 22 TABLE 5 TESTING EDFES REPORTS FILE NAMING CONVENTIONS REPORT TYPE GENTRAN TIBCO MAILBOX FTP MAILBOX EDFES Notifications T.xxxxx.EDS_RESPONSE.pn RSPxxxxx.RSP.REJECTED_ID TA1 T.xxxxx.EDS_REJT_IC_ISAIEA.pn X12xxxxx.X12.TMMDDCCYYHHMMS 999 T.xxxxx.EDS_REJT_FUNCT_TRANS.pn 999.999.999 999 T.xxxxx.EDS_ACCPT_FUNCT_TRANS.pn 999.999.999 277CA T.xxxxx.EDS_RESP_CLAIM_NUM.pn RSPxxxxx.RSP_277CA Table 6 below provides the EDPS reports file naming conventions by connectivity method. MAOs and other entities should note that Connect:Direct (NDM) users reports file naming conventions are user defined. TABLE 6 TESTING EDPS REPORTS FILE NAMING CONVENTIONS Table 7 below provides a description of the file name components, which will assist MAOs and other entities in identifying the report types. TABLE 7 FILE NAME COMPONENT DESCRIPTION FILE NAME COMPONENT DESCRIPTION RSPxxxxx The type of data RSP and a sequential number assigned by the server xxxxx X12xxxxx The type of data X12 and a sequential number assigned by the server xxxxx TMMDDCCYYHHMMS The Date and Time stamp the file was processed 999xxxxx The type of data 999 and a sequential number assigned by the server xxxxx RPTxxxxx The type of data RPT and a sequential number assigned by the server xxxxx EDPS_XXX Identifies the specific EDPS Report along with the report number (i.e., 002, etc.) XXXXXXX Seven (7) characters available to be used as a short description of the contents of the file RPT FILE Identifies if the file is a formatted report RPT or a flat file FILE layout 6.6.2 Production Reports File Naming Convention A different production reports file naming convention is used so that MAOs and other entities may easily identify reports generated and distributed during production. Table 8 below provides the reports file naming conventions per connectivity method for production reports. CONNECTIVITY METHOD TESTING NAMING CONVENTION FORMATTED REPORT TESTING NAMING CONVENTION FLAT FILE LAYOUT GENTRAN TIBCO T.xxxxx.EDPS_001_DataDuplicate_Rpt T.xxxxx.EDPS_002_DataProcessingStatus_Rpt T.xxxxx.EDPS_004_RiskFilter_Rpt T.xxxxx.EDPS_005_DispositionSummary_Rpt T.xxxxx.EDPS_006_EditDisposition_Rpt T.xxxxx.EDPS_007_DispositionDetail_Rpt T.xxxxx.EDPS_001_DataDuplicate_File T.xxxxx.EDPS_002_DataProcessingStatus_File T.xxxxx.EDPS_004_RiskFilter_File T.xxxxx.EDPS_005_DispositionSummary_ File T.xxxxx.EDPS_006_EditDisposition_ File T.xxxxx.EDPS_007_DispositionDetail_ File FTP RPTxxxxx.RPT.EDPS_001_DATDUP_RPT RPTxxxxx.RPT.EDPS_002_DATPRS_RPT RPTxxxxx.RPT.EDPS_004_RSKFLT_RPT RPTxxxxx.RPT.EDPS_005_DSPSUM_RPT RPTxxxxx.RPT.EDPS_006_EDTDSP_RPT RPTxxxxx.RPT.EDPS_007_DSTDTL_RPT RPTxxxxx.RPT.EDPS_001_DATDUP_File RPTxxxxx.RPT.EDPS_002_DATPRS_File RPTxxxxx.RPT.EDPS_004_RSKFLT_ File RPTxxxxx.RPT.EDPS_005_DSPSUM_ File RPTxxxxx.RPT.EDPS_006_EDTDSP_ File RPTxxxxx.RPT.EDPS_007_DSTDTL_ File 837 Institutional Companion Guide Version 38.0 July 2016. 23 TABLE 8 PRODUCTION EDFES REPORTS FILE NAMING CONVENTIONS 1. File Name Record 3. File Count Record REPORT TYPE GENTRAN TIBCO MAILBOX FTP MAILBOX EDFES Notifications P.xxxxx.EDS_RESPONSE.pn RSPxxxxx.RSP.REJECTED_ID TA1 P.xxxxx.EDS_REJT_IC_ISAIEA.pn X12xxxxx.X12.TMMDDCCYYHHMMS 999 P.xxxxx.EDS_REJT_FUNCT_TRANS.pn 999.999.999 999 P.xxxxx.EDS_ACCPT_FUNCT_TRANS.pn 999.999.999 277CA P.xxxxx.EDS_RESP_CLAIM_NUM.pn RSPxxxxx.RSP_277CA Table 9 below provides the production EDPS reports file naming conventions per connectivity method. TABLE 9 PRODUCTION EDPS REPORTS FILE NAMING CONVENTIONS 6.7 EDFES Notifications The EDFES distributes special notifications to submitters when encounters have been processed by the EDFES, but will not proceed to the EDPS for further processing. These notifications are distributed to MAOs and other entities, in addition to standard EDFES Acknowledgement Reports (TA1, 999, and 277CA) in order to avoid returned, unprocessed files from the EDS. Table 10 provides the file type, EDFES notification message, and EDFES notification message description. The file has an 80 character record length and contains the following record layout: a. Positions 1 7 Blank Spaces b. Positions 8 18 File Name: c. Positions 19 62 Name of the Saved File d. Positions 63 80 Blank Spaces 2. File Control Record a. Positions 1 4 Blank Spaces b. Positions 5 18 File Control: c. Positions 19 27 File Control Number d. Positions 28 80 Blank Spaces a. Positions 1 18 Number of Claims: CONNECTIVITY METHOD PRODUCTION NAMING CONVENTION FORMATTED REPORT PRODUCTION NAMING CONVENTION FLAT FILE LAYOUT GENTRAN TIBCO P.xxxxx.EDPS_001_DataDuplicate_Rpt P.xxxxx.EDPS_002_DataProcessingStatus_Rpt P.xxxxx.EDPS_004_RiskFilter_Rpt P.xxxxx.EDPS_005_DispositionSummary_Rpt P.xxxxx.EDPS_006_EditDisposition_Rpt P.xxxxx.EDPS_007_DispositionDetail_Rpt P.xxxxx.EDPS_001_DataDuplicate_File P.xxxxx.EDPS_002_DataProcessingStatus_File P.xxxxx.EDPS_004_RiskFilter_File P.xxxxx.EDPS_005_DispositionSummary_ File P.xxxxx.EDPS_006_EditDisposition_ File P.xxxxx.EDPS_007_DispositionDetail_ File FTP RPTxxxxx.RPT.PROD_001_DATDUP_RPT RPTxxxxx.RPT.PROD_002_DATPRS_RPT RPTxxxxx.RPT.PROD_004_RSKFLT_RPT RPTxxxxx.RPT.PROD_005_DSPSUM_RPT RPTxxxxx.RPT.PROD_006_EDTDSP_RPT RPTxxxxx.RPT.PROD_007_DSTDTL_RPT RPTxxxxx.RPT.PROD_001_DATDUP_File RPTxxxxx.RPT.PROD_002_DATPRS_File RPTxxxxx.RPT.PROD_004_RSKFLT_ File RPTxxxxx.RPT.PROD_005_DSPSUM_ File RPTxxxxx.RPT.PROD_006_EDTDSP_ File RPTxxxxx.RPT.PROD_007_DSTDTL_ File 837 Institutional Companion Guide Version 38.0 July 2016. 24 b. Positions 19 24 File Claim Count c. Positions 25 80 Blank Spaces 4. File Separator Record a. Positions 1 80 Separator (----------) 5. File Message Record a. Positions 1 80 FILE WAS NOT SENT TO THE EDPS BACK-END PROCESS FOR THE FOLLOWING REASON(S) 6. File | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_5 |
38.0 July 2016. 24 b. Positions 19 24 File Claim Count c. Positions 25 80 Blank Spaces 4. File Separator Record a. Positions 1 80 Separator (----------) 5. File Message Record a. Positions 1 80 FILE WAS NOT SENT TO THE EDPS BACK-END PROCESS FOR THE FOLLOWING REASON(S) 6. File Message Records a. Positions 1 80 File Message The report format example is as follows: FILE NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX FILE CONTROL: XXXXXXXXX NUMBER OF CLAIMS: 99,999 FILE WAS NOT SENT TO THE EDPS BACK-END PROCESS FOR THE FOLLOWING REASON(S) XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Table 10 provides the complete list of testing and production EDFES notification messages. TABLE 10 EDFES NOTIFICATIONS APPLIES TO NOTIFICATION MESSAGE NOTIFICATION MESSAGE DESCRIPTION All files submitted FILE ID (XXXXXXXXX) IS A DUPLICATE OF A FILE ID SENT WITHIN THE LAST 12 MONTHS The file ID must be unique for a 12 month period All files submitted SUBMITTER NOT AUTHORIZED TO SEND CLAIMS FOR PLAN (CONTRACT ID) The submitter is not authorized to send for this plan All files submitted PLAN ID CANNOT BE THE SAME AS THE SUBMITTER ID The Contract ID cannot be the same as the Submitter ID All files submitted AT LEAST ONE ENCOUNTER IS MISSING A CONTRACT ID IN THE 2010BB-REF02 SEGMENT The Contract ID is missing Production files submitted SUBMITTER NOT CERTIFIED FOR PRODUCTION The submitter must be certified to send encounters for production Tier 2 files submitted THE INTERCHANGE USAGE INDICATOR MUST EQUAL T The Institutional Tier 2 file is being sent with a P in the ISA15 field Tier 2 files submitted PLAN (CONTRACT ID) HAS (X,XXX) CLAIMS IN THIS FILE. ONLY 2,000 ARE ALLOWED The number of encounters for a Contract ID cannot be greater than 2,000 End-to-End Testing FILE CANNOT CONTAIN MORE THAN 6 ENCOUNTERS The number of encounters cannot be greater than 6 End-to-End Testing PATIENT CONTROL NUMBER IS MORE THAN 20 CHARACTERS LONG THE TC WAS TRUNCATED The Claim Control Number, including the Test Case Number, must not exceed 20 characters End-to-End Testing FILE CONTAINS (X) TEST CASE (X) ENCOUNTER(S) The file must contain two (2) of each test case Test NO TEST CASES FOUND IN THIS FILE This file was processed with the Interchange Usage Indicator T and the Submitter is not yet Certified 837 Institutional Companion Guide Version 38.0 July 2016. 25 APPLIES TO NOTIFICATION MESSAGE NOTIFICATION MESSAGE DESCRIPTION End-to-End Testing ADDITIONAL FILES CANNOT BE VALIDATED UNTIL AN MAO-002 REPORT HAS BEEN RECEIVED The MAO-002 report must be received before additional files can be submitted All files submitted FILE CANNOT EXCEED 5,000 ENCOUNTERS The maximum number of encounters allowed in a file All files submitted TRANSACTION SET (ST SE) (XXXXXXXXX) CANNOT EXCEED 5,000 CLAIMS There can only be 5,000 claims in each ST SE Loop All files submitted DATE OF SERVICE CANNOT BE BEFORE 2011 Files cannot be submitted with a date of service before 2011 All files submitted CAS ADJUSTMENT AMOUNT MUST NOT BE 0 The CAS Adjustment Amount cannot be zero (0). All files submitted BILLING PROVIDER LOOP IS MISSING The Billing Provider Loop must be present. 7.0 Front-End Edits CMS provides a list of the edits used to process all encounters submitted to the EDFES. The CMS 5010 Institutional Edits Spreadsheet identifies currently active and deactivated edits for MAOs and other entities to reference for programming their internal systems and reconciling EDFES Acknowledgement Reports. The CMS 5010 Institutional Edits Spreadsheet provides documentation regarding edit rules that explain how to identify an EDFES edit and the associated logic. The CMS 5010 Institutional Edits Spreadsheet also provides a change log that lists the revision history for edit updates. MAOs and other entities are able to access the CMS 5010 Institutional Edits Spreadsheet on the CMS website at: https: www.cms.gov Regulations-and-Guidance Guidance Transmittals 1. Select the current year in the left navigation column (e.g., 2015 Transmittals) 2. Key in 'EDI Front End Updates' in the 'Filter On' box 3. Select the most current transmittal to obtain the latest versions of the CEM Edits Spreadsheets 4. Click on the link(s) under 'Downloads' at the bottom of the page 7.1 Deactivated Front-End Edits Several CEM edits currently active in the CMS 5010 Institutional Edits Spreadsheet will be deactivated in order to ensure that syntactically correct encounters pass front-edit editing. Table 11 provides a list of the deactivated EDFES CEM edits. The edit reference column provides the exact reference for the deactivated edits. The edit description column provides the Claim Status Category Code (CSCC), the Claim Status Code (CSC), and the Entity Identifier Code (EIC), when applicable. The notes column provides a description of the edit reason. MAOs and other entities should reference the WPC website at www.wpc-edi.com for a complete listing of all CSCCs and CSCs. 837 Institutional Companion Guide Version 38.0 July 2016. 26 TABLE 11 837 INSTITUTIONAL DEACTIVATED EDFES EDITS EDIT REFERENCE EDIT DESCRIPTION EDIT NOTES X223.084.2010AA.NM109.050 CSCC A8: "Acknowledgement Rejected for relational field in error" CSC 496 "Submitter not approved for electronic claim submissions on behalf of this entity." EIC: 85 Billing Provider This Fee for Service edit validates the NPI and submitter ID number to ensure the submitter is authorized to submit on the provider s behalf. Encounter data cannot use this validation as we validate the plan number and submitter ID to ensure the submitter is authorized to submit on the plan s behalf. 2010AA.NM109 billing provider must be "associated" to the submitter (from a trading partner management perspective) in 1000A.NM109. X223.087.2010AA.N301.070 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 503: "Entity's Street Address" EIC: 85 Billing Provider Remove edit check for 2010AA N3 PO Box variations when ISA08 80881 (Institutional Payer Code). X223.084.2010AA.NM109.040 CSCC A8: "Acknowledgement Rejected for relational field in error." CSC 562: "Entity's National Provider Identifier (NPI)" EIC: 85 Billing Provider Valid NPI Crosswalk must be available for this edit. 2010AA.NM109 must be a valid NPI on the Crosswalk when evaluated with 1000B.NM109. X223.090.2010AA.REF02.050 CSCC A8: "Acknowledgement Rejected for relational field in error" CSC 562: "Entity's National Provider Identifier (NPI)" CSC 128: "Entity's tax id" EIC: 85 Billing Provider Valid NPI Crosswalk must be available for this edit. 2010AA.REF must be associated with the | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_6 |
valid NPI on the Crosswalk when evaluated with 1000B.NM109. X223.090.2010AA.REF02.050 CSCC A8: "Acknowledgement Rejected for relational field in error" CSC 562: "Entity's National Provider Identifier (NPI)" CSC 128: "Entity's tax id" EIC: 85 Billing Provider Valid NPI Crosswalk must be available for this edit. 2010AA.REF must be associated with the provider identified in 2010AA.NM109. X223.127.2010BB.REF.010 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 732: "Information submitted inconsistent with billing guidelines." CSC 560: "Entity's Additional Secondary Identifier." EIC: PR "Payer" This REF Segment is used to capture the Plan number as this is unique to encounter data submission only. The CEM applies the following logic: Non-VA claims: 2010BB.REF with REF01 "2U", "EI", "FY" or "NF" must not be present. VA claims: 2010BB.REF with REF01 "EI", "FY" or "NF" must not be present. This edit needs to remain off in order for the submitter to send in his plan number. X223.424.2400.SV202-7.025 CSCC A8: "Acknowledgement Rejected for relational field in error" CSC 306 Detailed description of service 2400.SV202-7 must be present when 2400.SV202-2 contains a non-specific procedure code. When using a not otherwise classified or generic HCPCS procedure code the CEM is editing for a more descriptive meaning of the procedure code. For example, the submitter is using J3490. The description for this HCPCS is Not Otherwise Classified (NOC) Code. 837 Institutional Companion Guide Version 38.0 July 2016. 27 EDIT REFERENCE EDIT DESCRIPTION EDIT NOTES X223.153.2300.CL103.015 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 234: "Patient discharge status" When 2300.CL103 value 20, 40, 41, or 42 is present, at least one occurrence of 2300.HI01-2 thru HI12-2 must 55 where HI01-1 is BH. X223.424.2400.SV203.060 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 400: "Claim is out of balance: CSC 583:"Line Item Charge Amount" CSC 643: "Service Line Paid Amount" SV203 must the sum of all payer amounts paid found in 2430 SVD02 and the sum of all line adjustments found in 2430 CAS Adjustment Amounts. X223.143.2300.CLM02.070 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 400: "Claim is out of balance" CSC 178: "Submitted Charges" 2300.CLM02 must the sum of all 2400.SV203 amounts. X223.143.2300.CLM02.080 CSCC A7: "Acknowledgement Rejected for Invalid Information " CSC 400: "Claim is out of Balance" CSC 672 "Payer's payment information is out of balance CLM02 must equal the sum of all 2320 CAS amounts and all 2430 CAS amounts and 2320 AMT02 (when AMT01 D). X223.389.2330B.DTP.030 IK304 2: "Unexpected Segment" If 2430 DTP with 573 is present, then 2330B DTP must not be present. 837 Institutional Companion Guide Version 38.0 July 2016. 28 7.2 Temporarily Deactivated Front-End Edits Table 12 provides a list of the temporarily deactivated EDFES Institutional CEM balancing edits in order to ensure that encounters that require balancing of monetary fields will pass front-end editing. Note: The Institutional edits listed in Table 12 are not all-inclusive and are subject to amendment. TABLE 12 837 INSTITUTIONAL TEMPORARILY DEACTIVATED EDFES EDITS EDIT REFERENCE EDIT DESCRIPTION EDIT NOTES X223.364.2320.AMT.040 CSCC A7: Acknowledgement Rejected for Invalid Information CSC 41: Special handling required at payer site CSC 286: Other Payer's Explanation of Benefits payment information CSC 732: Information submitted inconsistent with billing guidelines N A X223.109.2000B.SBR03.004 X223.109.2000B.SBR03.006 CSCC A8: Acknowledgement Rejected for relational field in error CSC 163: Entity s Policy Number CSC 732: Information submitted inconsistent with billing guidelines EIC IL: Subscriber N A X223.109.2000B.SBR04.004 X223.109.2000B.SBR04.007 CSCC A8: Acknowledgement Rejected for relational field in error CSC 663: Entity's Group Name CSC 732: Information submitted inconsistent with billing guidelines EIC IL: Subscriber N A 7.3 New EDFES Edits Table 13 provides a list of EDFES Institutional CEM edits recently added or revised that may impact encounter processing. TABLE 13 837 NEW INSTITUTIONAL EDFES EDITS Note: Table 13 will not be provided when there are no relevant enhancements implemented for the current release of the CMS EDS Companion Guides. 8.0 Duplicate Logic In order to ensure encounters submitted are not duplicates of encounters previously submitted, the EDS will perform header and detail level duplicate checking. If the header and or detail level duplicate checking determines that the file is a duplicate, the file will reject, and an error report will be returned to the submitter. 837 Institutional Companion Guide Version 38.0 July 2016. 29 8.1 Header Level When a file (ISA IEA) is received, the system assigns a hash total to the file based on the entire ISA IEA interchange. The EDS uses hash totals to ensure the accuracy of processed data. The hash total is a total of several fields or data in a file, including fields not normally used in calculations, such as the account number. At various stages in processing, the hash total is recalculated and compared with the original. If a file comes in later in a different submission, or a different submission of the same file, and gets the same hash total, it will reject as a duplicate. In addition to the hash total, the system also references the values collectively populated in ISA13, GS06, ST02, and BHT03. If two (2) files are submitted with the exact same values populated as a previously submitted and accepted file, the file will be considered a duplicate and the error message CSCC - A8 Acknowledgement Rejected for relational field in error, CSC -746 Duplicate Submission will be provided on the 277CA. 8.2 Detail Level Once an encounter is processed in the EDPS, it is stored in an internal repository, the Encounter Operational Data Store (EODS). If a new encounter is submitted that matches specific values on another stored encounter, the encounter will reject as a duplicate encounter. The encounter will be returned to the submitter with an error message identifying it as a duplicate encounter. Currently, the following values are the minimum set of items used for matching an encounter in the EODS: Beneficiary Demographic o Health Insurance Claim Number (HICN) Date of Service Type of Bill (TOB) Revenue Code(s) Procedure Code(s) and up to 4 modifiers Billing Provider NPI Charge (Billed) Amount Paid Amount (as populated at both the Header and Detail Levels) Paid Amounts by the MAO and other entity will only be used in the duplicate validation logic. 9.0 | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_7 |
of Service Type of Bill (TOB) Revenue Code(s) Procedure Code(s) and up to 4 modifiers Billing Provider NPI Charge (Billed) Amount Paid Amount (as populated at both the Header and Detail Levels) Paid Amounts by the MAO and other entity will only be used in the duplicate validation logic. 9.0 837 Institutional Business Cases In accordance with 45 CFR 160.103 of the HIPAA, Protected Health Information (PHI) is not included in the 837-I business cases. As a result, the business cases have been populated with fictitious information about the Subscriber, MAO, and provider(s). The business cases reflect 2012 dates of service. Although the business cases are provided as examples of possible encounter submissions, MAOs and other entities must populate valid data in order to successfully pass translator and CEM level editing. MAOs and other entities should direct questions regarding the contents of the EDS Test Case Specification to encounterdata cms.hhs.gov. Note: The business cases identified in the CMS EDS 837-I Companion Guide indicate paid amounts and DTP segments at the line level. 837 Institutional Companion Guide Version 38.0 July 2016. 30 The Adjudication or Payment Date (DTP 573 segment) must follow the paid amount. For example, if the paid amount is populated at the claim level, the DTP 573 segment must be populated at the claim level. If the paid amount is populated at the line level, the DTP 573 segment must be populated at the line level. 837 Institutional Companion Guide Version 38.0 July 2016. 31 9.1 Standard Institutional Encounter Business Scenario 1: Patient subscriber, Mary Dough, was admitted into Mercy Hospital complaining of heart pain. Happy Health Plan was the MAO. Mercy Hospital diagnosed Mary with Congestive Health Failure as the primary diagnosis and diabetes as an additional diagnosis. File String 1: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 200.00 11:A:1 A Y Y DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 HI BK:4280 HI BJ:4280 HI BF:25000 HI BR:3121:D8:20120330 HI BH:41:D8:20110501 BH:27:D8:20110715 BH:33:D8:20110718 BH:C2:D8:20110729 HI BE:30:::20 HI BG:01 NM1 71 1 JONES AMANDA AL XX 1005554104 837 Institutional Companion Guide Version 38.0 July 2016. 32 SBR P 18 XYZ1234567 16 AMT D 200.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 0300 HC:81099 200.00 UN 1 DTP 472 D8 20120330 SVD H9999 200.00 HC:81099 0300 1 DTP 573 D8 20120401 SE 50 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 33 9.2 Capitated Institutional Encounter Business Scenario 2: Patient subscriber, Mary Dough, is enrolled in Happy Health Plan and went to Mercy Hospital because she was experiencing leg pain. Mercy Hospital diagnosed Mary with diabetes and leg pain. Happy Health Plan has a capitated arrangement with Mercy Hospital. Note: For Institutional EDRs, the indicator of whether a record is capitated occurs at the header level. In the event that the MAO has a contractual arrangement with a provider under which certain services are paid on a FFS basis and other services are paid on capitated basis, the MAO should submit as a single EDR with the CN101(Contract Type Code) at the header level in LOOP 2300 left blank and populate the CAS segment at the line level within LOOP 2430 with a Group Reason Code of 24 to indicate a capitated service line. For FFS lines, the Group Reason Code should be populated using the codes submitted by the provider on the 835. If all lines in an institutional EDR are capitated, then the EDR should be submitted with the CN101(Contract Type Code) at the header level in LOOP 2300 set to 05. File String 2: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000331 1 P: GS HC ENH9999 80881 20120816 1144 30 X 005010X223A2 ST 837 0021 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 0.00 11:A:1 A Y Y 837 Institutional Companion Guide Version 38.0 July 2016. 34 DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 CN1 05 HI BK:4280 HI BJ:4280 HI BF:25000 HI BR:3121:D8:20120330 HI BH:41:D8:20110501 BH:27:D8:20110715 BH:33:D8:20110718 BH:C2:D8:20110729 HI BE:30:::20 HI BG:01 NM1 71 1 JONES AMANDA AL XX 1005554104 SBR P 18 XYZ1234567 ZZ AMT D 100.50 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 LX 1 SV2 0300 HC:81099 0.00 UN 1 DTP 472 D8 20120330 SVD H9999 100.50 HC:81099 0300 1 CAS CO 24 -100.50 DTP 573 D8 20120401 SE 50 0021 GE 1 30 IEA 1 | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_8 |
PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 LX 1 SV2 0300 HC:81099 0.00 UN 1 DTP 472 D8 20120330 SVD H9999 100.50 HC:81099 0300 1 CAS CO 24 -100.50 DTP 573 D8 20120401 SE 50 0021 GE 1 30 IEA 1 000000331 837 Institutional Companion Guide Version 38.0 July 2016. 35 9.3 Chart Review Institutional Encounter No Linked ICN Business Scenario 3: Patient subscriber, Mary Dough, went to Mercy Hospital because she was experiencing leg pain. Happy Health Plan was the MAO. Happy Health Plan performs a chart review at Mercy Hospital and determines that a diagnosis for Mary Dough was never submitted on a claim. The medical record does not contain enough information to submit a full claim, yet there is enough information to support the diagnosis and link the chart review encounter back to the medical record. Happy Health Plan submits a chart review encounter with no linked ICN to add the diagnosis. File String 3: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999899 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 0.00 11:A:1 A Y Y DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 PWK 09 AA HI BK:4280 HI BJ:4280 HI BF:25000 HI BR:3121:D8:20120330 HI BH:41:D8:20110501 BH:27:D8:20110715 BH:33:D8:20110718 BH:C2:D8:20110729 837 Institutional Companion Guide Version 38.0 July 2016. 36 HI BE:30:::20 HI BG:01 NM1 71 1 JONES AMANDA AL XX 1005554104 SBR P 18 XYZ1234567 16 AMT D 0.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 0300 HC:81099 0.00 UN 1 SVD H9999 65.00 HC:81099 1 DTP 472 D8 20120330 SE 49 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 37 9.4 Chart Review Institutional Encounter Linked ICN (Add Diagnoses) Business Scenario 4: Patient subscriber, Mary Dough, went to Mercy Hospital because she was experiencing leg pain. Happy Health Plan was the MAO. Mercy Hospital submits the encounter to CMS and receives an ICN of 1294598098746. Happy Health Plan performs a chart review related to ICN 1294598098746 and determines that additional diagnoses were not originally reported for diabetes and high cholesterol. Note: In the event that a linked chart review encounter requires the addition and deletion of multiple diagnosis codes, MAOs should submit a single linked chart review encounter (2300 CLM05-3 1 (Original)) to add all necessary diagnoses, and submit a separate linked chart review encounter (also 2300 CLM05-3 1 (Original)) to delete all necessary diagnosis codes. MAOs should submit a replacement chart review encounter (2300 CLM05-3 7 ) only in the event previously stored chart review data should be completely replaced. MAOs should submit a void chart review encounter (2300 CLM05-3 8 ) only when the original chart review encounter (linked or unlinked) requires deletion. File String 4: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999899 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 0.00 11:A:1 A Y Y DTP 096 TM 0958 837 Institutional Companion Guide Version 38.0 July 2016. 38 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 PWK 09 AA REF F8 1294598098746 HI BK:25000 (First diagnosis to be added, BK not repeatable) HI BF:2720 (Second diagnosis to be added, BF repeatable through HI12) NM1 71 1 JONES AMANDA AL XX 1005554106 SBR P 18 XYZ1234567 16 AMT D 0.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 0300 HC:81099 0.00 UN 1 SVD H9999 87.50 HC:81099 1 DTP 472 D8 20120330 SE 50 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 39 9.5 Chart Review Institutional Encounter Linked ICN (Delete Diagnoses) Business Scenario 5: Patient subscriber, Mary Dough, went to Mercy Hospital because she was experiencing leg pain. Happy Health Plan was the MAO. Happy Health Plan submits the encounter to CMS and receives an ICN of 1294598098746. Happy Health Plan performs a chart review related to ICN 1294598098746 and determines that the original encounter should not have reported diagnoses related to diabetes and high cholesterol, which should be deleted. Happy Health Plan submits a Chart Review encounter to delete the relevant diagnoses. Note: In the event that a linked chart review encounter requires the addition and deletion of multiple diagnosis codes, MAOs should submit a single linked chart review encounter (2300 CLM05-03 1 (Original)) to add all necessary diagnoses, and submit a separate linked chart | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_9 |
Review encounter to delete the relevant diagnoses. Note: In the event that a linked chart review encounter requires the addition and deletion of multiple diagnosis codes, MAOs should submit a single linked chart review encounter (2300 CLM05-03 1 (Original)) to add all necessary diagnoses, and submit a separate linked chart review encounter (also 2300 CLM05-03 1 (Original)) to delete all necessary diagnosis codes. MAOs should submit a replacement chart review encounter (2300 CLM05-03 7 ) only in the event previously stored chart review data should be completely replaced. MAOs should submit a void chart review encounter (2300 CLM05-3 8 ) only when the original chart review encounter (linked or unlinked) requires deletion. File String 5: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999899 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 0.00 11:A:1 A Y Y 837 Institutional Companion Guide Version 38.0 July 2016. 40 DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 PWK 09 AA REF F8 1294598098746 REF EA 8 HI BK:25000 (First diagnosis to be deleted, BK not repeatable) HI BF:2720 (Second diagnosis to be deleted, BF repeatable through HI12) NM1 71 1 JONES AMANDA AL XX 1005554106 SBR P 18 XYZ1234567 16 AMT D 0.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 0300 HC:81099 0.00 UN 1 SVD H9999 87.50 HC:81099 1 DTP 472 D8 20120330 SE 50 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 41 9.6 Complete Replacement Institutional Encounter Business Scenario 6: Patient subscriber, Mary Dough, went to Mercy Hospital because she was experiencing heart pain. Mercy Hospital diagnosed Mary with Congestive Heart Failure and diabetes. Happy Health Plan submits the encounter to CMS and receives an ICN 1122978564098. After further investigation, it was determined that Happy Health Plan submitted the encounter with an incorrect payment. Happy Health Plan submits a replacement encounter to CMS, using ICN 1122978564098 to correct the payment amount. File String 6: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000554 1 P: GS HC ENH9999 80881 20120816 1144 80 X 005010X223A2 ST 837 0567 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 200.00 11:A:7 A Y Y DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330-20120331 CL1 2 9 01 REF F8 1222978564098 HI BK:4280 HI BJ:4280 HI BR:3121:D8:20120330 HI BH:41:D8:20110501 BH:27:D8:20110715 BH:33:D8:20110718 BH:C2:D8:20110729 HI BE:30:::20 837 Institutional Companion Guide Version 38.0 July 2016. 42 HI BG:01 NM1 71 1 JOHNSON AMANDA AL XX 1005554104 SBR P 18 XYZ1234567 16 CAS CO 39 120.00 AMT D 80.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235048769 LX 1 SV2 0300 HC:81099 200.00 UN 1 DTP 472 D8 20120330 SVD H9999 0.00 HC:99212 1 DTP 573 20120401 SE 50 0567 GE 1 80 IEA 1 000000554 837 Institutional Companion Guide Version 38.0 July 2016. 43 9.7 Complete Deletion Institutional Encounter Business Scenario 7: Patient subscriber, Mary Dough, was admitted to Miracle Health Center because she was experiencing abdominal pain. Happy Health Plan is the MAO. Dr. Smart at Miracle Health Center diagnosed Mary with a gastric ulcer. Happy Health Plan submits the encounter to CMS and receives ICN 1212487000032. Happy Health Plan then determines that the claim for Mary s visit was not adjudicated in their internal system. Happy Health Plan submits a void encounter to delete the previously submitted encounter. File String 7: ISA 00 00 ZZ ENH9999 ZZ 80881 120430 114 4 00501 000000298 1 P: GS HC ENH9999 80881 20120430 1144 82 X 005010X222A1 ST 837 0290 005010X222A1 BHT 0019 00 3920394930206 20120428 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 1 MIRACLE HEALTH CENTER XX 1299999999 N3 123 CENTRAL DRIVE N4 NORFOLK VA 235139999 REF EI 765879876 PER IC ELIZABETH SMART TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 47 MB NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 2997677856479709654A 100.50 11:B:8 Y A Y Y REF F8 1212487000032 HI BK:53190 SBR P 18 XYZ1234567 16 CAS CO 223 100.50 AMT D 0.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 837 Institutional Companion Guide Version 38.0 July | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_10 |
REF F8 1212487000032 HI BK:53190 SBR P 18 XYZ1234567 16 CAS CO 223 100.50 AMT D 0.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 837 Institutional Companion Guide Version 38.0 July 2016. 44 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 HC:99212 100.50 UN 1 1 DTP 472 D8 20120401 SVD H9999 0.00 HC:99212 1 DTP 573 D8 20120403 SE 41 0290 GE 1 82 IEA 1 000000298 837 Institutional Companion Guide Version 38.0 July 2016. 45 9.8 Atypical Provider Institutional Encounter Business Scenario 8: Patient subscriber, Mary Dough, receives personal care services from an atypical provider. Happy Health Plan was the MAO. File String 8: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000032 1 P: GS HC ENH9999 80881 20120816 1144 35 X 005010X223A2 ST 837 0039 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY SERVICES XX 1999999976 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 199999997 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578799A 50.00 83:A:1 A Y Y DTP 434 RD8 20120330-20120331 CL1 9 9 01 HI BK:78099 NTE ADD 048052 SBR P 18 XYZ1234567 16 AMT D 50.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 837 Institutional Companion Guide Version 38.0 July 2016. 46 REF T4 Y LX 1 SV2 0300 HC:D0999 50.00 UN 1 DTP 472 D8 20120330 SVD H9999 50.00 HC:D0999 0300 1 DTP 573 D8 20120401 SE 41 0039 GE 1 35 IEA 1 000000032 837 Institutional Companion Guide Version 38.0 July 2016. 47 9.9 Paper Generated Institutional Encounter Business Scenario 9: Patient subscriber, Mary Dough, receives services from Mercy Center. Mercy Center submits the claim to Happy Health Plan on a UB-04. Happy Health Plan is the MAO and converts the paper claim into an electronic submission. File String 9: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000032 1 P: GS HC ENH9999 80881 20120816 1144 35 X 005010X223A2 ST 837 0039 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY CENTER XX 1234999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 128752354 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578799A 50.00 83:A:1 A Y Y DTP 434 RD8 20120330-20120331 CL1 9 9 01 PWK OZ AA HI BK:78099 SBR P 18 XYZ1234567 16 AMT D 50.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST 837 Institutional Companion Guide Version 38.0 July 2016. 48 N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 0300 HC:D0999 50.00 UN 1 DTP 472 D8 20120330 SVD H9999 50.00 HC:D0999 0300 1 DTP 573 D8 20120403 SE 42 0039 GE 1 35 IEA 1 000000032 837 Institutional Companion Guide Version 38.0 July 2016. 49 9.10 True Coordination of Benefits Institutional Encounter Business Scenario 10: Patient subscriber, Mary Dough, was admitted into Mercy Hospital complaining of heart pain. Mercy Hospital diagnosed Mary with congestive heart failure and diabetes. Happy Health Plan is the MAO submitting the encounter to CMS. Mary Dough also has healthcare coverage through Other Health Plan, the secondary payer, who has distributed a payment for Mary. File String 10: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578799A 712.00 11:A:1 A Y Y DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 HI BK:78901 NM1 71 1 JONES AMANDA AL XX 1005554104 SBR P 18 XYZ1234567 16 AMT D 700.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE 837 Institutional Companion Guide Version 38.0 July 2016. 50 N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 SBR T 18 XYZ3489388 16 CAS CO 223 700.00 AMT D 12.00 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 OTHER HEALTH PLAN XV PAYER01 N3 400 W 21 ST N4 NORFOLK VA 235059999 DTP 573 D8 20120401 REF T4 Y LX 1 SV2 0300 HC:81099 712.00 UN 1 DTP 472 D8 20120330 SVD H9999 700.00 HC:D0999 0300 1 CAS CO 45 12.00 DTP 573 D8 | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_11 |
235099999 NM1 PR 2 OTHER HEALTH PLAN XV PAYER01 N3 400 W 21 ST N4 NORFOLK VA 235059999 DTP 573 D8 20120401 REF T4 Y LX 1 SV2 0300 HC:81099 712.00 UN 1 DTP 472 D8 20120330 SVD H9999 700.00 HC:D0999 0300 1 CAS CO 45 12.00 DTP 573 D8 20120401 SE 56 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 51 9.11 Bundled Institutional Encounter Business Scenario 11: Patient subscriber, Mary Dough, was admitted into Mercy Hospital complaining of heart pain. Happy Health Plan was the MAO. Mercy Hospital diagnosed Mary with Congestive Health Failure as the primary diagnosis and diabetes. File String 11: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HOSPITAL XX 1299999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 100.00 11:A:1 A Y Y DTP 096 TM 0958 DTP 434 RD8 20120330-20120331 DTP 435 D8 20120330 CL1 2 9 01 HI BK:4280 HI BJ:4280 HI BF:25000 HI BR:3121:D8:20120330 HI BH:41:D8:20110501 BH:27:D8:20110715 BH:33:D8:20110718 BH:C2:D8:20110729 HI BE:30:::20 HI BG:01 NM1 71 1 JONES AMANDA AL XX 1005554104 837 Institutional Companion Guide Version 38.0 July 2016. 52 SBR P 18 XYZ1234567 16 AMT D 9.48 OI Y Y NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 HC:82374 50.00 UN 1 1 DTP 472 D8 20120401 SVD H9999 9.48 HC:80051 1 CAS CO 45 40.52 DTP 573 D8 20120403 LX 2 SV2 HC:82435 50.00 UN 1 11 DTP 472 D8 20120401 SVD H9999 0.00 HC:80051 1 1 CAS OA 97 50.00 DTP 573 D8 20120403 SE 57 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 53 9.12 Skilled Nursing Facility Encounter Business Scenario 12: Patient subscriber, Mary Dough, was admitted into Mercy Health and Rehabilitation SNF for intensive physical therapy services. Happy Health Plan was the MAO. The SNF admitted Mary for inpatient monitoring and physical therapy for a fractured femur. Her length of stay was from 07 10 2014 through 07 26 2014. File String 12: ISA 00 00 ZZ ENH9999 ZZ 80881 120816 114 4 00501 000000031 1 P: GS HC ENH9999 80881 20120816 1144 31 X 005010X223A2 ST 837 0034 005010X223A2 BHT 0019 00 3920394930203 20120814 1615 CH NM1 41 2 HAPPY HEALTH PLAN 46 ENH9999 PER IC MICAH THOMAS TE 5555552222 NM1 40 2 EDSCMS 46 80881 HL 1 20 1 NM1 85 2 MERCY HEALTH AND REHAB XX 1299999999 N3 876 MERCY DRIVE N4 NORFOLK VA 235089999 REF EI 344232321 PER IC ELIZABETH SMITH TE 9195551111 HL 2 1 22 0 SBR S 18 XYZ1234567 MA NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 DMG D8 19390807 F NM1 PR 2 EDSCMS PI 80881 N3 7500 SECURITY BLVD N4 BALTIMORE MD 212441850 REF 2U H9999 CLM 22350578967509876984536578798A 25453.42 21:A:1 A Y Y DTP 096 TM 0958 DTP 434 RD8 20140710-20140726 DTP 435 D8 20140710 CL1 2 9 01 HI BK:82021 HI BJ:82021 HI BH:50:D8:20140726 NM1 71 1 LEACH ELIZA AL XX 1005554104 SBR P 18 XYZ1234567 16 AMT D 25453.42 OI Y Y 837 Institutional Companion Guide Version 38.0 July 2016. 54 NM1 IL 1 DOUGH MARY MI 672148306 N3 1234 STATE DRIVE N4 NORFOLK VA 235099999 NM1 PR 2 HAPPY HEALTH PLAN XV H9999 N3 705 E HUGH ST N4 NORFOLK VA 235049999 REF T4 Y LX 1 SV2 0022 HP:RML21 0 UN 1 1 LX 2 SV2 0420 HC:97110 25453.42 UN 14 DTP 472 RD8 20140712-20140726 SVD H9999 25453.42 HC:98925 0022 14 DTP 573 D8 20140930 SE 57 0034 GE 1 31 IEA 1 000000031 837 Institutional Companion Guide Version 38.0 July 2016. 55 10.0 Encounter Data Institutional Processing and Pricing System Edits After an Institutional encounter passes translator and CEM level editing and receives an ICN on the 277CA acknowledgement report, the EDFES then transfers the encounter to the Encounter Data Institutional Processing and Pricing System (EDIPPS), where editing, processing, pricing, and storage occurs. In order to assist MAOs and other entities with submission of encounter data through the EDIPPS, CMS has provided the current list of the EDIPPS edits identified in Table 14. Note: The edit descriptions listed into Table 14 were revised to identify a maximum of 41 characters in order to display a more comprehensive explanation of edits on the MAO-002 Reports. The EDIPPS edits are organized in nine (9) different categories, as provided in Table 14, Column 2. The EDIPPS edit categories include the following: Validation Provider Beneficiary Reference Limit Conflict Pricing Duplicate NCCI Table 14, Column 3 identifies two (2) edit dispositions: Informational and Reject. Informational edits will cause the encounter to be flagged; however, the Informational edit will not cause processing and or pricing to cease. Reject edits will cause an encounter to stop processing and or pricing, and the MAO or other entity must resubmit the encounter through the EDFES. The encounter must then pass translator and C1 level editing prior to transferring the data to the EDIPPS for reprocessing. The EDIPPS edit description, as found in Table 14, Column 4, is included on the EDPS transaction reports to provide further information for the MAO or other entity to identify the specific reason for the edit generated. If there is no reject edit at the header level and at least one of the lines is accepted, | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_12 |
in Table 14, Column 4, is included on the EDPS transaction reports to provide further information for the MAO or other entity to identify the specific reason for the edit generated. If there is no reject edit at the header level and at least one of the lines is accepted, then the encounter is accepted. If there is no reject edit at the header level, but all lines reject, then the encounter will reject. If there is a reject edit at the header level, the encounter will reject. Table 14 reflects only the currently programmed EDIPPS edits. MAOs and other entities should note that, as testing progresses, it may be determined that the current edits require modifications, additional edits may be necessary, or edits may be deactivated. MAOs and other entities must always reference the most recent version of the CMS EDS 837-I Companion Guide to determine the current edits in the EDIPPS. 837 Institutional Companion Guide Version 38.0 July 2016. 56 TABLE 14 ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS EDIPPS EDIT EDIPPS EDIT CATEGORY EDIPPS EDIT DESCRIPTION EDIPPS EDIT ERROR MESSAGE 00010 Validation Reject From DOS Greater Than TCN Date 00011 Validation Reject Missing DOS in Header Line 00012 Validation Reject DOS Prior to 2012 00025 Validation Reject Through DOS After Receipt Date 00030 Validation Reject ICD-10 Dx Not Allowed 00035 Validation Reject ICD-9 Dx Not Allowed 00175 Validation Reject Verteporfin 00195 Validation Informational Wrong Setting for Autologous PRP 00200 Validation Informational Clinical Trial Billing Error 00265 Validation Reject Correct Replace or Void ICN Not in EODS 00699 Validation Reject Void Must Match Original 00750 Pricing Reject Service(s) Not Covered Prior To 4 1 2013 00755 Validation Reject Void Encounter Already Void Adjusted 00760 Validation Reject Adjusted Encounter Already Void Adjusted 00762 Validation Reject Unable to Void Rejected Encounter 00764 Validation Reject Original Must Be Chart Review to Void 00765 Validation Reject Original Must Be Chart Review to Adjust 00775 Validation Reject Unable to Adjust Rejected Encounter 00780 Validation Reject Adjustment Must Match Original 00785 Validation Reject Linked Encounter Not in EODS 00790 Validation Reject Linked Encounter is Voided Adjusted 00795 Validation Reject Linked Encounter is Rejected 00800 Validation Reject Parent ICN Not Allowed for Original 00805 Validation Reject Deleted Diagnosis Code Note Allowed 01405 Provider Reject Sanctioned Provider 01415 Provider Informational Rendering Provider Not Eligible For DOS 02106 Beneficiary Informational Invalid Beneficiary Last Name 02110 Beneficiary Reject Beneficiary HICN Not On File 02112 Beneficiary Reject DOS After Beneficiary DOD 02120 Beneficiary Reject Beneficiary Gender Mismatch 02125 Beneficiary Reject Beneficiary DOB Mismatch 02240 Beneficiary Reject Beneficiary Not Enrolled In MAO For DOS 02256 Beneficiary Reject Beneficiary Not Part C Eligible For DOS 03015 Validation Reject HCPCS Code Invalid for DOS 03022 Pricing Reject Invalid CMG for IRF Encounter 03165 Validation Reject Telehealth Facility Fee Not Allowed 17085 Validation Reject CC 40 Required for Same Day Transfer 17100 Validation Reject DOS Required for HH Encounter 17257 Validation Informational Rev Code 091X Not Allowed 17310 Validation Reject Rev Code 036X Requires Surg Proc Code 837 Institutional Companion Guide Version 38.0 July 2016. 57 TABLE 14 ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS EDIPPS EDIT EDIPPS EDIT CATEGORY EDIPPS EDIT DESCRIPTION EDIPPS EDIT ERROR MESSAGE 17330 Reference Reject RAP Not Allowed 17404 Validation Reject Duplicate CPT HCPCS and Unit Exceeds 1 17407 Validation Reject Modifier Requires HCPCS Code 17735 Validation Reject Modifier Not Within Effective Date 18010 Reference Informational Age and Dx Code Conflict 18012 Reference Informational Gender and Dx Code Conflict 18018 Reference Informational Gender and CPT HCPCS Conflict 18130 Reference Reject Duplicate Principal Dx Code 18135 Reference Reject Principal Dx Code is Manifestation Code 18140 Reference Reject Principal Dx Code is E-Code 18145 Reference Reject Unacceptable Dx Code 18260 Reference Reject HCPCS Required with Submitted Rev Code 18270 Validation Informational Rev Code and HCPCS Required 18300 Validation Reject FQHC Payment Code is Invalid Missing 18305 Validation Reject Invalid Missing FQHC Qualifying Visit 18310 Validation Reject Required FQHC Revenue Code is Missing 18315 Validation Reject Item Service Not Covered Under FQHC 18500 Conflict Informational Multiple CPT HCPCS for Same Service 18540 Reference Informational CPT HCPCS Service Unit Out Of Range 18705 Validation Reject Invalid Discharge Status 18710 Validation Reject Missing Invalid POA Indicator 18730 Reference Informational Invalid Modifier Format 18905 Validation Reject Age Is 0 Or Exceeds 124 20270 Validation Reject From Thru Dates Equal - Day Count 1 20450 Validation Reject Attending Physician is Sanctioned 20455 Validation Informational Operating Provider Is Sanctioned 20495 Validation Reject Revenue Code is Non-Billable for TOB 20500 Conflict Reject Invalid DOS for Rev Code Billed 20505 Conflict Reject Correct Ambulance HCPCS Rev Code Required 20510 Conflict Reject Rev Code 054X Requires Specific HCPCS 20515 Conflict Informational Immunization Dx Must Align with HCPCS 20520 Validation Informational Invalid Ambulance Pick-up Location 20525 Validation Reject Multiple Ambulance Pick-up Locations 20530 Validation Informational Missing Ambulance Pick-up Zip Code 20835 Pricing Reject Service Line DOS Not Within Header DOS 20980 Pricing Informational Provider Cannot Bill TOB 12X or 22X 21925 Pricing Reject Swing Bed SNF Conditions Not Met 21950 Pricing Reject Line Level DOS Required 21951 Pricing Informational No OSC 70 or Covered Days Less Than 3 21958 Pricing Informational Rehab Therapy Ancillary Codes Required 837 Institutional Companion Guide Version 38.0 July 2016. 58 TABLE 14 ENCOUNTER DATA INSTITUTIONAL PROCESSING AND PRICING SYSTEM (EDIPPS) EDITS EDIPPS EDIT EDIPPS EDIT CATEGORY EDIPPS EDIT DESCRIPTION EDIPPS EDIT ERROR MESSAGE 21976 Validation Informational OSC 70 Dates Outside of Coverage Period 21979 Validation Reject Charges for Rev Code 0022 Must Be Zero 21980 Validation Reject CC D2 Requires Change in One HIPPS 21994 Validation Informational From Date Greater Than Admit Date 22015 Validation Informational Number of Days Conflicts With HH Episode 22020 Validation Informational Conflict Between CC and OSC 22095 Validation Reject Encounter Must Be Submitted on 837-P DME 22100 Validation Informational Rev Code 0023 Invalid for DOS 22135 Validation Reject Multiple Rev Code 0023 Lines Present 22205 Validation Reject Service Line Missing DOS 22220 Validation Reject Admit Provider Effective Date Conflict 22225 Validation Informational Missing Provider Specific Record 22280 Validation Reject Rev Code 277 Invalid for a HH 22290 Validation Reject Service | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_13 |
Code 0023 Invalid for DOS 22135 Validation Reject Multiple Rev Code 0023 Lines Present 22205 Validation Reject Service Line Missing DOS 22220 Validation Reject Admit Provider Effective Date Conflict 22225 Validation Informational Missing Provider Specific Record 22280 Validation Reject Rev Code 277 Invalid for a HH 22290 Validation Reject Service Line Requires DOS 22320 Validation Informational Missing ASC Procedure Code 22340 Validation Reject ESRD Diagnosis Code Missing 22355 Validation Reject Inpatient Service Line Error 22375 Validation Reject Item Service Not Covered for RHC 22390 Validation Reject HIPPS Code Required for SNF HH (DOS on or after 7 1 2014) 22395 Validation Reject HIPPS Codes Conflicts with Revenue Code (DOS on or after 7 1 2014) 22400 Validation Reject HP Qualifier Must Exist for HIPPS Code (DOS on or after 7 1 2014) 22405 Validation Reject Occurrence Code 55 DOD Required (DOS on or after 01 01 2013) 22410 Pricing Reject Invalid Service(s) for TOB 22415 Pricing Reject Revenue Code 0274 Required 22420 Validation Reject TOB 33X Invalid for DOS 22430 Validation Reject HCPCS Codes with Invalid TOB 25000 NCCI Informational CCI Error 27000 Validation Reject Height or Weight Value Exceeds Limit 98300 Duplicate Reject Exact Inpatient Duplicate Encounter 98315 Duplicate Reject Linked Chart Review Duplicate 98320 Duplicate Reject Chart Review Duplicate 98325 Duplicate Reject Service Line(s) Duplicated 837 Institutional Companion Guide Version 38.0 July 2016. 59 10.1 EDIPPS Edits Enhancements Implementation Dates As the EDS matures, the EDPS may require enhancements to the EDIPPS editing logic. As enhancements occur, CMS will provide the updated information (i.e., disposition changes and activation or deactivation of an edit). Table 15 provides MAOs and other entities with the implementation dates for enhancements made to the EDIPPS since the last release of the CMS EDS 837-I Companion Guide. TABLE 15 EDIPPS EDITS ENHANCEMENTS IMPLEMENTATION DATES EDIT EDIT DISPOSITION EDIT DESCRIPTION ENHANCEMENT ENHANCEMENT DATE 00800 Reject Parent ICN Not Allowed for Original New Edit Implemented 7 8 16 00805 Reject Deleted Diagnosis Code Not Allowed New Edit Implemented 7 8 16 18730 Informational Invalid Modifier Format Changed to Informational Disposition 7 8 16 22375 Reject Item Service Not Covered For RHC New Edit Implemented 7 8 16 Note: Table 15 will not be provided when there are no enhancements implemented for the current release of the CMS EDS Companion Guides. 10.2 EDIPPS Edits Prevention and Resolution Strategies In order to assist MAOs and other entities with the prevention of potential errors in their encounter data submission and with resolution of edits received on the generated MAO-002 reports, CMS has provided comprehensive strategies and scenarios. CMS has identified strategies and scenarios in three (3) phases. 10.2.1 EDIPPS Edits Prevention and Resolution Strategies Phase I: Frequently Generated EDIPPS Edits Table 16 outlines Phase 1 of the prevention and resolution strategies for Institutional edits most frequently generated on the MAO-002 reports. TABLE 16 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE I Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17310 Rev Code 036X Requires Surg Proc Code Reject Revenue Code 036X must be submitted with a required surgical ICD-9 CM procedure code for TOBs 11X, 18X, or 21X. Scenario: Life and Health Associates submitted an encounter for Galaxy Suburb Hospital for a prostate cryosurgery performed on 5 15 2012. The encounter was populated with Revenue Code of 036X, but did not include ICD-9-CM procedure code 6062. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17407 Modifier Requires HCPCS Code Reject Service line submitted with HCPCS modifier, but not the required HCPCS code. Verify that codes modifiers are accurate. 837 Institutional Companion Guide Version 38.0 July 2016. 60 Scenario: Dr. Whitty submitted the HCPCS modifier code 25- Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure, without the appropriate level of E M service. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17735 Modifier Not Within Effective Date Reject Modifier not active for DOS reported. Submitter must verify that modifiers reported are valid and current. Scenario: As a follow up to a postoperative surgery on 8 1 2012, Dr. Whitty submitted HCPCS modifier code 21- Prolonged evaluation and management services on 9 28 2012; however, the modifier was deactivated on 9 1 2012. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20270 From Thru Dates Equal - Day Count 1 Reject Inpatient encounter contains same from and through DOS; however, the day count reported in Loop 2320 MIA15 does not equal 1. Verify that DOS are accurate or that day count is equal to 1. Scenario: Nightline Hospital admitted a patient at 8 p.m. on 10 23 2012 and the patient was discharged at 2 p.m. on 10 24 2012. Dawn to Dusk Healthcare submitted the encounter with a day count of 2 for admission, although the overnight stay is considered one (1) day. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20505 Correct Ambulance HCPCS Rev Code Required Reject Revenue Code 540 populated without appropriate ambulance HCPCS codes and or a unit greater than 1 for the HCPCS code. Also provide HCPCS mileage codes. Scenario: Blue Flight Health Plan submitted an encounter for ground ambulance services with Revenue Code 540; however, the HCPCS code was not populated. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20510 Rev Code 054X Requires Specific HCPCS Reject HCPCS code is not valid for submission with Revenue Code 540. Use an appropriate HCPCS code from the list of HCPCS codes acceptable for submission with Revenue Code 540. Scenario: Blue Flight Health Plan submitted a ground transportation ambulance Revenue Code 540 with a HCPCS code A0021-Out of State Per Mile, which was valid for the service, but is invalid for Medicare. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20530 Missing Ambulance Pick-up Zip Code Informational Submitter should provide a valid nine (9)-digit ZIP code for ambulance pick-up location on ambulance encounters submitted on an Institutional encounter. (See formatting guidance in Section 5.1, Table 4.) Scenario: Mystery Health Plan submitted an encounter on behalf of Rush Ambulance with an ambulance ZIP code populated as 0 in Loop segment 2300 HI01-05. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20835 Service Line | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_14 |
encounters submitted on an Institutional encounter. (See formatting guidance in Section 5.1, Table 4.) Scenario: Mystery Health Plan submitted an encounter on behalf of Rush Ambulance with an ambulance ZIP code populated as 0 in Loop segment 2300 HI01-05. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20835 Service Line DOS Not Within Header DOS Reject Line level DOS reported that does not fall within from and through DOS range reported on header level of encounter. Verify the accuracy of all DOS. Scenario: Who Knows Hospital admitted Janet Doe on 6 1 2012 and discharged her on 6 10 2012. Padre Care Plan submitted an inpatient encounter on behalf of Who Knows Hospital for Ms. Doe. The service line DOS were correct; however, the claim header indicated that Ms. Doe was admitted on 6 6 2012 and discharged on 6 12 2012. 837 Institutional Companion Guide Version 38.0 July 2016. 61 10.2.2 EDIPPS Edits Prevention and Resolution Strategies Phase II: Common EDPS Edits Table 17 outlines Phase II for common edits generated in all subsystems of the EDPS (Professional, Institutional, and DME). TABLE 17 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE II Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00010 From DOS Greater Than TCN Date Reject Encounter must have a DOS prior to submission date. Scenario: Perfect Health of America submitted an encounter to the EDS on 5 10 2012 for a knee replacement performed at Wonderful Hills Mediplex for DOS of 6 20 2012. The encounter was rejected because the from DOS was after the date of encounter submission. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00011 Missing DOS in Header Line Reject Encounter header and line levels must include from and through DOS (procedure or service start date). Scenario: Chloe Pooh was admitted to Regional Port Hospital on 10 21 2012 for a turbinectomy and was released on 10 22 2012. Regional Port Hospital submitted a claim to Robbins Health for the surgical procedure. Robbins Health submitted the encounter to the EDS, but did not include the through DOS of 10 22 2012. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00012 DOS Prior to 2012 Reject Encounter must contain 2012 through DOS for each line. Scenario: Ion Health submitted an encounter with DOS from 12 2 2011 through 12 28 2011, for an inpatient admission at Better Health Hospital. EDS will only process encounters that include 2012 through DOS or later. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00025 Through DOS After Receipt Date Reject Encounter submitted with a service line through DOS that occurred after the date the encounter was submitted. Scenario: Leverage Community Health submitted an encounter on 8 23 2012 for a myringotomy performed by Dr. Earwell. The service line DOS for the procedure was on 8 29 2012. The encounter was rejected because the encounter was submitted to the EDS prior to the DOS listed on the encounter. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00265 Correct Replace or Void ICN Not in EODS Reject Replacement or void encounter submitted with an invalid ICN. Verify accuracy of ICN on the returned MAO-002 report. Scenario: Chance Medical Services submitted an encounter to the EDS and received an MAO-002 report with an accepted ICN of 123456789. The encounter required an adjustment (void or replacement). Chance Medical Services submitted a replacement encounter using ICN 234567899. The replacement encounter was rejected because there was no original record in the EDS for this ICN with the same Submitter ID. 837 Institutional Companion Guide Version 38.0 July 2016. 62 TABLE 17 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE II (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00699 Void Must Match Original Reject When submitting a void, MAOs must match the linked ICN, HICN, Last Name, First Name, TOB, Submitted Charges, DOS, Payer ID, and the service lines of an accepted encounter stored in the EODS. Note: The EDPS will validate the beneficiary s demographic data (HICN, Last Name, First Name) according to the Medicare Beneficiary Database (MBD), as well as validate the beneficiary s Billing Provider NPI and Rendering Provider NPI (if applicable) prior to posting edit 00699. Scenario: Grantham Healthcare submitted an encounter for pre-operation lab work for Juno Brac containing five (5) service lines. Torchlight Healthcare then submitted a void encounter for the same annual physical; however, the void encounter contained only four (4) of the five (5) original service lines. Torchlight Healthcare received an MAO-002 report with edit 00699 for the void encounter because one (1) of the service lines from the original encounter was not included on the void encounter. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 01405 Sanctioned Provider Reject Submitter must ensure that provider (billing and or rendering) was not suspended or terminated from providing services for Medicare beneficiaries during the time(s) of service indicated on the encounter. Scenario: Dr. Domuch performed a cystectomy for Wally Dowright on 10 2 2012. Dr. Domuch submitted a claim to Dermis Health Plan, who adjudicated the claim and submitted an encounter to the EDS. The EDS returned the encounter to Dermis Health Plan with edit 01405 because Dr. Domuch s privileges were suspended, effective 8 29 2012, for one (1) year; therefore, Dr. Domuch was not authorized to perform this procedure. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 01415 Rendering Provider Not Eligible For DOS Informational Verify that NPI is accurate and that the provider was eligible for DOS submitted. Scenario: ABC Care Plan submitted an encounter for a procedure performed by Dr. Destiny on 2 14 2012. The EDPS provider reference files indicate that Dr. Destiny s NPI was not effective until 2 16 2012. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02106 Invalid Beneficiary Last Name Informational Verify that last name populated on the encounter matches the last name listed in CMS systems. Scenario: Blue Skies Rural Health submitted an encounter for patient Ina Batiste-Rhogin. The CMS system listed the patient as Ina Rhogin. The EDPS processed and accepted the encounter with an informational flag indicating that the name provided on the encounter was not identical to the | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_15 |
name listed in CMS systems. Scenario: Blue Skies Rural Health submitted an encounter for patient Ina Batiste-Rhogin. The CMS system listed the patient as Ina Rhogin. The EDPS processed and accepted the encounter with an informational flag indicating that the name provided on the encounter was not identical to the name listed in the CMS systems. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02110 Beneficiary HICN Not On File Reject Verify that HICN populated on the encounter is valid in CMS systems. Scenario: Bright Medical Center submitted a claim to Sunshine Complete Health for an office visit for Mr. Everett Banks for DOS of 5 26 2012. Sunshine Complete Health submitted an encounter to the EDS. The EDS rejected the encounter with edit 02110, because the HICN populated on the encounter was not on file in the CMS systems. 837 Institutional Companion Guide Version 38.0 July 2016. 63 TABLE 17 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE II (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02112 DOS After Beneficiary DOD Reject Verify that DOS submitted is accurate and does not exceed the beneficiary DOD. Scenario: Mountain Hill Health submitted an encounter for an inpatient admission for Ray Rayson for DOS of 7 15 2012. EDPS was unable to process the encounter because the CMS systems indicated Mr. Rayson expired on 7 13 2012. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02120 Beneficiary Gender Mismatch Reject Verify that gender populated on the encounter is accurate and matches gender listed in CMS systems. Scenario: Jenna Jorgineski went to Lollipop Lab for a sleep study on 9 4 2012. Lollipop Lab submitted a claim for the sleep study to Capital City Community Care with Ms. Jorgineski s gender identified as male. Capital City Community Care submitted the encounter. The EDS processed and accepted the encounter. The MAO-002 report was returned with edit 02120, because Ms. Jorgineski s gender was listed as female in the CMS systems. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02125 Beneficiary DOB Mismatch Reject Verify that DOB populated on the encounter matches DOB listed in CMS systems. The EDPS will accept these encounters within plus or minus two (2) years of beneficiary s birth year. Note: CMS anticipates that the change in this edit will be short-term and expects plan sponsors to improve their submission of DOBs. Scenario: Watchman Health submitted an encounter to the EDS for Texas Joe, listing Mr. Joe s DOB as 9 8 1965. The CMS systems listed Mr. Joe s DOB as 9 8 1956. The EDS returned the MAO-002 report to Watchman Health with edit 02125 due to the conflicting dates of birth beyond the two (2)-year variance. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02240 Beneficiary Not Enrolled In MAO For DOS Reject Verify that beneficiary was enrolled in your contract during DOS on the encounter. If the beneficiary is not enrolled in your contract for the DOS on the encounter, do not submit the encounter. Encounters should only be submitted for DOS in which the beneficiary is enrolled in your contract. Scenario: Gabrielle Boyd was admitted to Faith Hospital for an appendectomy on 6 11 2012 and was discharged on 6 14 2012. Faith Hospital submitted the claim for the hospital admission to Adams Healthcare. Adams Healthcare adjudicated the claim and submitted an encounter to the EDS on 7 12 2012. Ms. Boyd s effective date with Adams Healthcare was 7 1 2011. The EDS returned an MAO-002 report to Adams Health with edit 02240 because Ms. Boyd was not enrolled with the health plan for the DOS submitted by Faith Hospital. 837 Institutional Companion Guide Version 38.0 July 2016. 64 TABLE 17 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE II (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 02256 Beneficiary Not Part C Eligible For DOS Reject Verify that beneficiary was enrolled in Part C for DOS listed on the encounter. Encounters should not be submitted for beneficiaries not enrolled with the contract for the DOS on the received claim. Encounters should only be submitted for DOS for which the beneficiary is actually enrolled with your contract. Scenario: On 7 4 2012, Gail Williams has severe chest pains and goes to the emergency room for a chest x-ray at Underwood Memorial Hospital. At the time of the emergency room visit, Ms. Williams only has Part A Medicare coverage, and her Part C Medicare coverage is effective 8 1 2012. Underwood Memorial submits the claim to AmeriHealth. AmeriHealth submits an encounter to the EDS, which is rejected with edit 02256, because Ms. Williams is not covered under Part C Medicare for the DOS. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 25000 CCI Error Informational Ensure CCI code pairs are appropriately used. Ensure that CCI single codes meet the MUE allowable units of service (UOS). Scenario: Hippos Health Plan submitted an encounter to the EDS with a DOS of 5 5 2012 and HCPCS code 15780 and two (2) units of service. The returned MAO-002 report indicated an informational edit of 25000 because HCPCS code 15780 dermabrasion, is only valid for one (1) unit of service per day. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 98325 Service Line(s) Duplicated Reject Verify encounter was not previously submitted and or the service line does not contain the exact same data elements as a previously submitted service line on the same encounter (Refer to the Section 8.0 Duplicate Logic in this companion guide for duplicate logic validation elements.) Note: The EDPS will bypass edit logic for 98325 when modifier 59, 62, 66, 76, 77, and or 91 is submitted on one (1) of multiple service lines containing the exact same data elements. Scenario: Sanford Health Systems submitted an encounter on 6 15 2015 for a claim received from Sky High Hospital containing two (2) service lines for 15-minute therapy services. The encounter lines submitted were the same for the timed procedure code, totaling 35 minutes and should have been submitted with two (2) units of service under the total time rather than as separate duplicate lines. 837 Institutional Companion Guide | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_16 |
Hospital containing two (2) service lines for 15-minute therapy services. The encounter lines submitted were the same for the timed procedure code, totaling 35 minutes and should have been submitted with two (2) units of service under the total time rather than as separate duplicate lines. 837 Institutional Companion Guide Version 38.0 July 2016. 65 10.2.3 EDIPPS Edits Prevention and Resolution Strategies Phase III: General EDIPPS Edits Table 18 outlines Phase III for a portion of the remaining Institutional edits generated on the MAO-002 Encounter Data Processing Status Reports. Section 10.2.3 will be updated in future releases of the Institutional Companion Guide until all remaining edits are identified. TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00195 Wrong Setting for Autologous PRP Informational Encounters containing HCPCS code G0460 must only be billed with TOB 12X, 13X, 22X, 23X, 71X, 75X, 77X, or 85X. Scenario: New Balance Home Health submitted an encounter for the purpose of billing Autologous Platelet-Rich Plasma (PRP) for a Mr. Garret s non-healing wound. The service was submitted using HCPCS Code G0460 and TOB 34X. The EDS posted error code 00195 because Home Health providers cannot administer this service. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00200 Clinical Trial Billing Error Informational Clinical trial encounters must contain Modifier Q0, Condition Code 30, and clinical trial-specific ICD-9 10 Diagnosis Code V70.7 Z00.6. Scenario: Coagulate Community Health submitted a clinical trial encounter for patient Mr. Bumbly. The service was submitted with modifier Q0 and ICD-9 diagnosis code V70.7, but did not contain Condition Code 30, as required for clinical trial submissions to the EDS. The EDS posted error code 00200 because the clinical trial encounter must contain Condition Code 30. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18010 Age and Dx Code Conflict Informational Verify that diagnosis populated on the encounter is age appropriate for beneficiary Scenario: Clear Path Health submitted an encounter to the EDS for services provide to Mr. Jackson Leigh, who is 85-yrs old. The diagnosis provided on the encounter was V20.2-routine child health check. The MAO-002 report returned contained an informational edit of 18010 because the diagnosis provided was not appropriate for an 85-yr old. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18018 Gender and CPT HCPCS Conflict Informational Gender provided for beneficiary does not agree with procedure service identified on the encounter. Verify gender populated on encounter matches date in the CMS systems. Ensure that the procedure code is accurate and appropriate. Scenario: Claims Health submitted an encounter for Jane Johnson with procedure code 58150-Total Hysterectomy. However, the gender populated on the encounter identified Ms. Johnson as a male. The MAO-002 report was returned with an informational error of 18018. CMS recommends that Claims Health verify the gender on Ms. Johnson s HICN information to ensure that it is corrected. 837 Institutional Companion Guide Version 38.0 July 2016. 66 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18135 Principal Dx is Manifestation Code Reject Encounter submitted using a code for underlying disease or symptom instead of a principal diagnosis. Ensure that primary diagnosis is valid. Scenario: Arbor Meadows Health submitted an encounter for an inpatient admission for Ms. Anabel Greaves. The diagnosis submitted on the encounter was 3214-Meningitis due to sarcoidosis. The EDS rejected the encounter because 3214 is not a primary diagnosis, but is a manifestation code for a condition related to the diagnosis. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18260 Invalid Rev Code Reject Encounter submitted with a Revenue Code not related to services provided or a Revenue Code not used. Scenario: Home Sweet Home submitted a claim to Foundation Health for Home Health services provided to Ms. Jean. Foundation Health submitted the encounter to the EDS using Revenue Code 0022. The encounter was rejected for edit 18260 because Foundation Health used a SNF revenue code for a Home Health encounter. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18270 Rev Code and HCPCS Required Informational Certain revenue codes require HCPCS codes on the same service lines. TOBs 12X, 13X, 14X, 74X, 75X, and 76X billed without condition code 41 and include a relevant revenue code that requires a HCPCS code will receive this edit. Scenario: Julie Barber was seen by Dr. Jo at Saint Mary Hospital for a hearing evaluation. Dr. Jo submitted a TOB 141 encounter with HCPCS code 92506 (Speech Hearing Evaluation) but did not include revenue code 0440. The MAO submitted the encounter to the EDS which posted edit 18270 to advise the MAO that revenue codes are required with the submitted HCPCS code. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18300 FQHC Payment Code is Invalid Missing Reject An FQHC encounter (TOB 77X) must include a valid payment HCPCS code (G0466, G0467, G0468, G0469, or G0470) on the encounter service line for each billed service date. Scenario: Heelum Health Center submitted an FQHC encounter using bill type 77X and only submitted HCPCS code G0463. The EDPS rejected the encounter because the encounter did not contain an FQHC payment HCPCS code. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18305 Invalid Missing FQHC Qualifying Visit Reject FQHC encounters (TOB 77X) must include a qualifying visit procedure code related to the FQHC payment codes G0466, G0467, G0468, G0469, or G0470 for the same date of service. Scenario: Howard Cankle was treated by Heelum Health Center on 11 20 2014 for an annual wellness visit (G0468). Heelum Health Center submitted an encounter (bill type 77X) for Howard Cankle with visit code 92002 (eye exam, new patient). The EDPS rejected the service line because 92002 is not a valid visit code for payment code G0468. 837 Institutional Companion Guide Version 38.0 July 2016. 67 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18310 Required FQHC Revenue Code is Missing Reject FQHC encounters (TOB 77X) must include a valid revenue code on the same service line for the payment HCPCS codes G0466, G0467, G0468, G0469, or G0470. Scenario: | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_17 |
PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18310 Required FQHC Revenue Code is Missing Reject FQHC encounters (TOB 77X) must include a valid revenue code on the same service line for the payment HCPCS codes G0466, G0467, G0468, G0469, or G0470. Scenario: Heelum Health Center submitted an encounter (TOB 77X) for Eileen Bentley s annual eye exam (FQHC payment code G0467, visit code 92012) and revenue code 0530. The EDPS rejected the service line because revenue code 0530 is used for Osteopathic Services. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18315 Item Service Not Covered Under FQHC Reject All FQHC encounter service lines must contain only qualified FQHC services. Scenario: Heelum Health Center submitted an encounter (TOB 77X) including a service line for Dr. Smart s professional fees. The EDPS rejected the service line because Dr. Smart s professional fees are not acceptable FQHC services even though Dr. Smart is an FQHC provider. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18540 CPT HCPCS Service Unit Out Of Range Informational Procedures submitted with number of units not permitted by the procedure will receive this edit. Scenario: Cinderella Hospital submitted an encounter with HCPCS code 51860 for the bladder wound repair of Rob Snyder and billed two (2) units for the service. The encounter was rejected because submitters can only bill one (1) unit with HCPCS code 51860. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18705 Invalid Discharge Status Reject Providers must use the correct patient status code in loop 2300 and segment CL103 in conjunction with the submitted type of bill and beneficiary status. Scenario: Crisis Clinton Hospital submitted a TOB 112 encounter for Gary Fargo and the patient status code 01 was populated. The EDS posted edit 18705 as the encounter should have included patient status code 30 (still a patient) since TOB 112 was used for a continuous stay patient. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 21950 Line Level DOS Required Reject Certain procedures services require date(s) of service at the service line. The EDPS will post error code 21950 when an Institutional encounter submitted with HCPCS codes other than Q0163 through Q0181 does not contain service line date(s) of service. Scenario: Norview East Hospital submitted an encounter for Claire Beauchamp for an inpatient stay where continuous glucose monitoring was performed. The encounter service line contained HCPCS code 95250 but no service line dates of service. The EDS rejected the encounter due to missing DOS at the service line. 837 Institutional Companion Guide Version 38.0 July 2016. 68 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 21958 Rehab Therapy Ancillary Codes Required Informational The EDS will notify MAOs when Rehabilitation Therapy encounters submitted through TOB 18X or 21X and revenue code 0022 do not contain the proper combination of HIPPS codes and related Rehabilitation Therapy Ancillary Revenue Codes. Scenario: Sleeping Beauty Skilled Nursing Facility (SNF) submitted a TOB 21X encounter containing HIPPS Code RUAxx, but none of the following rehabilitation ancillary codes: 42X, 43X, or 44X. The EDS posted error code 21958 since this encounter contained an inaccurate combination of HIPPS codes and related Rehabilitation Therapy Ancillary Revenue Codes. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 21980 CC D2 Requires Change in One HIPPS Reject Replacement encounter submitted with condition code D2; however, the associated HIPPS code was not revised to indicate the replacement. Scenario: Marxton Health sent a replacement encounter to the EDS on behalf of Here For You Health, which contained condition code of D2 and an appropriate reason code to revise the HIPPs code originally submitted, but the HIPPS code itself was not revised. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00755 Void Encounter Already Void Adjusted Reject Submitter has previously voided an encounter and is attempting to void the same encounter. Submitter should review returned MAO-002 reports to confirm processing of the voided encounter prior to resubmission of the void. Scenario: Happy Trails Health Plan submitted a void encounter on 10 10 2012. Happy Trails Health Plan voided the same encounter, in error, on 10 15 2012, prior to receiving the MAO-002 report for the initial void encounter, which was returned on 10 16 2012. The MAO-002 report for the subsequent voided encounter was returned with edit 00755 due to the submission of the second void encounter. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00760 Adjusted Encounter Already Void Adjusted Reject Submitter has previously voided an encounter and is attempting to replace the same voided encounter. Submitter should review returned MAO-002 reports to confirm processing of the voided encounter prior to resubmission replacement. Scenario: On 8 20 2012, Pragmatic Health submitted a replacement encounter for ICN 123456789 to correct a CPT code. However, Pragmatic Health had already submitted a void for the same ICN on 8 18 2012, but had not yet received the MAO-002 report by 8 20 2012. Pragmatic Health received edit 00760 on a subsequent MAO-002 report because the EDPS had already processed the void encounter submitted on 8 18 2012. 837 Institutional Companion Guide Version 38.0 July 2016. 69 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00762 Unable to Void Rejected Encounter Reject Submitter is attempting to void a previously rejected encounter. Submitter should review returned MAO-002 reports to confirm the rejected encounter. Scenario: On 7 20 2012, Hero Health Plan submitted an encounter with an invalid HICN. On 7 26 2012, Hero Health Plan attempted to void the encounter due to the invalid HICN without referencing the MAO-002 report, dated 7 25 2012, that indicated that the encounter was rejected. On 8 1 2012, Hero Health Plan received an MAO-002 report with edit 00762 for the voided encounter because the original encounter had already been processed and rejected. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17330 RAP Not Allowed Reject Encounter submissions are not allowed for Type of Bill 322 or 332 (Request for Anticipated Payment) Scenario: Magic Morning Health Plan submitted an encounter | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_18 |
the voided encounter because the original encounter had already been processed and rejected. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17330 RAP Not Allowed Reject Encounter submissions are not allowed for Type of Bill 322 or 332 (Request for Anticipated Payment) Scenario: Magic Morning Health Plan submitted an encounter to the EDS for BackHome Health (a primary HHA) with TOB 322. The encounter was rejected because the EDS does not accept Request for Anticipated Payment (RAP) encounters. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18012 Gender and Dx Code Conflict Informational Encounter submitted with a beneficiary gender that does not agree with the diagnosis populated on the encounter. Scenario: Hindsight Health submitted an encounter for JuneBug Hospital for Mr. James Jewet with diagnosis code 641.1 Hemorrhage from placenta previa. The encounter was rejected because the diagnosis submitted is a female specific diagnosis. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18130 Duplicate Principal Dx Code Reject Secondary diagnosis code submitted is a duplicate of the primary diagnosis code. Scenario: Solo Health Services submitted an encounter with a diagnosis code 413.9 in the BK (primary diagnosis) and BF (additional diagnosis) qualifier fields for the same service line. The encounter was rejected for duplicate primary diagnoses. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18145 Unacceptable Dx Code Reject The diagnosis code populated on the encounter is invalid or incorrectly populated. Scenario: Hopewell Health Plan submitted an encounter to the EDS for Cornerstone Hospital for services provide to Colonel Marcus on 2 3 2012. The diagnosis populated on the encounter was 518.5 Pulmonary Insufficiency Following Trauma or Surgery. The encounter was rejected for an unacceptable diagnosis because diagnosis code was deleted and deemed invalid effective 10 1 2011. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 21994 From Date Greater Than Admit Date Informational Encounter submitted with a 'from' date prior to the date of the beneficiary s admission. Scenario: Allison Oop was admitted to Mad Hatter Nursing Facility at 2:46 AM on 4 1 2012. Holiday Health submitted the SNF encounter to the EDS with an admit date of 4 1 2012, but the service line from date was listed as 3 29 2012. 837 Institutional Companion Guide Version 38.0 July 2016. 70 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22220 Admit Provider Effective Date Conflict Reject Admission date indicated on encounter occurred before the provider s NPI was deemed active effective. Note: The EDPS will validate bill types prior to posting edit 22220. Scenario: Halo Home Health submitted an encounter to the EDS for Mr. Sweets admission on 1 28 2011 for DOS from 2 1 2012 through 2 11 2012 with NPI 0002220001. The encounter was rejected because the NPI effective date was 2 2 2012, after the admission date. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00764 Original Must Be a Chart Review to Void Reject Submitter must ensure that, if the void encounter (frequency code 8 ) is populated with PWK01 09 and PWK02 AA, the original encounter submission was a chart review encounter populated with PWK01 09 and PWK02 AA. The submitter must also ensure that the ICN references the initial chart review encounter, not the original full encounter. Scenario: On 1 12 2013, Paisley Community Health submitted an original encounter for Mr. Jolly Jones to the EDS and received the accepted ICN of 3029683010582. On 2 2 2013, Paisley Community Health submitted a chart review encounter to the EDPS to delete a diagnosis code from the original encounter and received the accepted ICN of 5039530285074. In April 2013, Paisley Community Health performed another chart review of Mr. Jones medical records and discovered that the service was never provided. Paisley Community Health submitted a void encounter to the EDS using the reference ICN of 3029683010582 (the original encounter ICN) and populated PWK01 09 and PWK02 AA. The EDS rejected the encounter because the ICN referenced was for the original encounter, not the initial chart review. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 00765 Original Must Be a Chart Review to Adjust Reject Ensure that, if the replacement encounter (frequency code 7 ) is populated with PWK01 09 and PWK02 AA, the original encounter submission was a chart review encounter populated with PWK01 09 and PWK02 AA. The submitter must also ensure that the ICN references the initial chart review encounter, not the original encounter. The replacement chart review (frequency code 7 ) must contain all data elements, including all relevant diagnosis codes populated on the original linked chart review encounter (frequency code 1 ). Important Note: The accepted replacement chart review submission will supersede any previous chart review encounter to which it is linked. Scenario: Flashback Health performed a chart review for Prosperous Living Medical Center. Flashback Health discovered two (2) additional diagnosis codes for an encounter previously submitted for Ms. Leanne Liberty. Flashback Health submitted an initial chart review encounter using the frequency code of 7. The EDS rejected the chart review encounter submission because initial chart review encounters should contain a frequency code 1. 837 Institutional Companion Guide Version 38.0 July 2016. 71 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17404 Duplicate CPT HCPCS and Unit Exceeds 1 Reject Encounter should not be submitted with a unit of greater than 1 when any of the following HCPCS codes are provided for a pap smear on a single DOS: Q0060, Q0061, P3000, P3001, Q0091, G0123, G0124, G0143, G0144, G0145, G0147, and G0148 nor can duplicate pap smear HCPCS Codes be submitted for the same day. Scenario: Dr. Michaels performed a pap smear on Miss Annabelle Lee prior to a gynecological procedure. The lab lost the test sample. Dr. Michaels repeated the Pap smear and performed the gynecological procedure. Group Health Plan submitted the encounter for both of Miss Lee s pap smears, using HCPCS code Q0060, and her surgical procedure. The encounter was rejected because Medicare will not allow more than one (1) unit for Q0060 for a single service. Edit | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_19 |
Pap smear and performed the gynecological procedure. Group Health Plan submitted the encounter for both of Miss Lee s pap smears, using HCPCS code Q0060, and her surgical procedure. The encounter was rejected because Medicare will not allow more than one (1) unit for Q0060 for a single service. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18140 Principal Dx Code is E-Code Reject Submitter must ensure that an e-code is submitted as a subsequent diagnosis code. An E-code is never allowed as a primary principal diagnosis code and must not be populated using the BK qualifier Scenario: Marney Gentos was admitted to Home Hospital for second degree burns. Fantasy Life Health Plan submitted the encounter to the EDS and received an accepted ICN. Fantasy Life Health Plan later performed a chart review and located an additional diagnosis code for services provided during Ms. Gentos stay at Home Hospital. Fantasy Life submitted a chart review encounter to the EDS with a single diagnosis code of E9581 Injury-burn, fire. The EDS rejected the chart review submission because e-codes must never be submitted without a primary principal diagnosis. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18905 Age Is 0 Or Exceeds 124 Reject The age of the patient identified on the encounter must not contain non-numeric values; or the age must not be populated as 0 or greater than 124 years old Scenario: Munali Mohair, a 27-yr old female was admitted to Petunia Mills General Hospital for an overnight stay due to complications following an outpatient procedure. Petunia Mills submitted a claim to Flowery Lanes Health with Ms. Mohair s DOB listed as 9 23 1985. Flowery Lanes Health submitted the encounter to the EDS with Ms. Mohair s DOB listed as 9 23 1885, due to a typographical error. The EDS returned edit 18905 on the MAO-002 report. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20450 Attending Physician is Sanctioned Reject Submitter must ensure that the attending provider was not suspended or terminated from providing services to Medicare beneficiaries during the time(s) of service indicated on the encounter Scenario: Dr. Jernigan, attending physician at Hospice Hotel, made rounds on 1 4 2013, for fellow physician due to an emergency. Hospice Hotel submitted Dr. Jernigan s claim to Better Health. Better Health submitted the encounter to the EDS. Dr. Jernigan s privileges were terminated on 12 20 2012, and he was not authorized to provide services for Hospice patients. Better Health received an MAO-002 report with a reject edit of 20450. 837 Institutional Companion Guide Version 38.0 July 2016. 72 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20455 Operating Provider Is Sanctioned Informational Submitter must ensure that the operating provider was not suspended or terminated from providing surgical services to Medicare beneficiaries during the time(s) of service indicated on the encounter Scenario: Dr. Madhatter performed a cholecystectomy at Highway Hospital on 3 12 2013. Highway Hospital submitted an Institutional claim to Providers Health Plan. Providers Health submitted the encounter to the EDS on 5 6 2013. It was discovered that Dr. Madhatter s operating surgical privileges were suspended on 3 3 2013. The EDS returned the MAO- 002 report to Providers Health with edit 20455. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20515 Immunization Dx Must Align with HCPCS Informational Administration of the Hepatitis B Vaccine must include relevant HCPCS codes and ICD-9 diagnosis code V05.3 (ICD- 10 code Z23 once required) or this edit will post Scenario: Elizabeth C.K. is a patient at Baltimore Metro ESRD facility. Elizabeth recently received the Hepatitis B Vaccine. Baltimore Metro ESRD submitted encounter with HCPCS code 90740 but failed to include diagnosis code V05.3. The EDS posted error code 20515 since the required ICD-9 diagnosis code V05.3 was not included in the encounter for the service. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20520 Invalid Ambulance Pick-up Location Informational Encounters for ambulance services must contain a valid nine (9)-digit ZIP code when revenue code 0540 is used and loop 2300 HI01-02 A0. Scenario: Family Health submitted an encounter for ambulance services provided by Monarch Medical Transport, but populated the ambulance pick-up location field (Loop segment 2300 HI01-05) as 9999999.98 (invalid). The EDS will accept the encounter and inform the submitter that a valid ambulance pick up ZIP code is required on all ambulance encounters. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 20525 Multiple Ambulance Pick-up Locations Reject Ambulance encounters cannot be submitted containing multiple iterations of loop 2300 HI01-01 BE and HI01-02 A0 Scenario: Round About Health submitted an encounter for ambulance services provided by Maybach Medical Transport. Round About Health submitted the same ZIP code twice for the pick-up location. The EDS rejected the encounter due to multiple ZIP codes listed for the ambulance pick-up location for one (1) patient on the same day. 837 Institutional Companion Guide Version 38.0 July 2016. 73 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 27000 Height or Weight Value Exceeds Limit Reject Encounters submitted with TOB 72X Values for A8 and A9 must be submitted in kilograms. For Value Code A8: Weight must not exceed 318.2 Kg (700 lbs.). For Value Code A9: Height must not exceed 228.6 Kg (7ft 6 in) Scenario: Mr. Nestle Parks, a 432 lb. male, was admitted to Mountain Top Memorial Hospital with kidney failure due to ESRD. River Run Health Plan submitted an encounter to the EDS for services provided to Mr. Parks during his stay at Mountain Top Memorial. The encounter contained Mr. Parks weight in Loop 2300 HI Value Code A8 segment at 432.0. The encounter was rejected with edit 27000 because the A8 value exceeded the allowable value of 318.2 kg. The encounter should have been submitted with Mr. Parks weight identified as 196.36, because the EDS requires that the measurements be populated in kilograms. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17257 Rev Code 091X Not Allowed Informational Medicare no longer accepts Revenue Code 910 for Psychiatric Psychological Services. Ensure that the | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_20 |
have been submitted with Mr. Parks weight identified as 196.36, because the EDS requires that the measurements be populated in kilograms. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17257 Rev Code 091X Not Allowed Informational Medicare no longer accepts Revenue Code 910 for Psychiatric Psychological Services. Ensure that the revenue code submitted for psychiatric services is current and valid. Scenario: Mr. Zane Zany was admitted to Far Side Institution due to severe depression. Way Out There Health Care submitted an encounter on behalf of Far Side Institution populated with revenue code 0910, for services provided to Mr. Zany during his admission from 12 15 2012 to 1 14 2013. The EDPS rejected the encounter submission because, as of October 2003, revenue code 0910 was no longer a valid and acceptable Medicare revenue code. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 18730 Invalid Modifier Format Informational Submitter must ensure that the modifier on the encounter is acceptable and valid for EDS submission. Ensure that the format is accurate and the appropriate characters are used. Scenario: Pinky Marvelous was admitted to Check-In Memorial Hospital for a radical mastectomy of her left breast. Check-In Memorial submitted a claim for the surgical procedure to Gallant Health Plan. Gallant Health Plan submitted the encounter to the EDS, populated with CPT 19307, modifier L6. The EDPS posted edit 18730 because the modifier was not entered accurately. The correct submission should be CPT 19307, modifier LT. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22015 Number of Days Conflicts With HH Episode Informational Submitter must ensure that the sum of the from and through dates for the episode of care does not exceed 60 days Scenario: Big Bell Home Health submitted a claim to Whamo Health Plan for Home Health services provided to Major Colonel from 2 3 2013 through 4 17 2013. Whamo Health Plan submitted the encounter to the EDS with the from and through dates of 2 3 2013 through 4 17 2013 on one (1) service line. The encounter was rejected because the episode of care exceeded the required maximum of 60 days. 837 Institutional Companion Guide Version 38.0 July 2016. 74 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22095 Encounter Must Be Submitted on 837-P DME Reject If the NPI on the encounter identifies a DME Supplier, the submitter must use the Payer ID of 80887 to indicate the service is for DMEPOS. Note: When the Payer ID must be changed for an encounter submitted to the EDS, MAOs and other entities must first void the original encounter, then submit a new encounter with the correct Payer ID. Scenario: Reach Rehab submitted an encounter for an electric hospital bed provided for Mr. Anton upon his discharge from Meyers Medical Center. Reach Rehab Services submitted the encounter to the EDS using the Institutional payer ID of 80882.The encounter was rejected because, although Mr. Anton was discharged from the hospital and received care that would be submitted on an Institutional encounter, services provided by Reach Rehab were specific to DMEPOS. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22135 Multiple Rev Code 0023 Lines Present Reject TOB 32X Home Health encounters must not contain more than one (1) service line containing revenue code 0023. Only one (1) revenue code is defined for each prospective payment system that requires HIPPS codes. Scenario: Harmony Home Health submitted an encounter with two (2) service lines containing HIPPS codes HBFK2 and HAEJ1. Harmony Home Health submitted separate revenue code 0023 service lines for each HIPPS code service line. The EDS rejected the encounter because revenue code 0023 may not be used more than once on a single Home Health encounter in conjunction with HIPPS codes. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22225 Missing Provider Specific Record Reject Encounter was submitted that contains a provider NPI that is not identified in the EDPS provider tables as a participating Medicare provider. Scenario: Ipse Institutional Hospital submitted an encounter file to the EDS for an inpatient procedure performed by Dr. Wymee using NPI 0000000000. The EDPS rejected the encounter because Dr. Wymee was not identified in the EDS as a participating Medicare provider. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 22020 Conflict Between CC and OSC Reject Encounters submitted with condition code C3 (Partial Approval) must contain Occurrence Span Code (OSC) MO to indicate the service dates that were approved. Scenario: Blue Bellman was admitted to The Best Nursing Facility on 3 3 2013 and discharged on 4 26 2013. The Quality Improvement Organization (QIO) reviewed the claim submitted to Service Plus Health Plan by The Besting Nursing Facility and denied service dates from 4 3 2013 through 4 26 2013. Service Plus Health Plan submitted the approved dates of service (DOS) using condition code C3, but did not populate the encounter with the MO modifier to indicate that the 3 3 2013 through 4 2 2013 DOS were approved. 837 Institutional Companion Guide Version 38.0 July 2016. 75 TABLE 18 EDIPPS EDITS PREVENTION AND RESOLUTION STRATEGIES PHASE III (CONTINUED) Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 21951 No OSC 70 or Covered Days Less Than 3 Informational Skilled Nursing Facility (SNF) encounters submitted using revenue code 0022 and TOB 21X, 22X, or 23X must include the submission of Occurrence Span Code 70 to indicate the dates of a qualifying hospital stay of at least three (3) consecutive days, which qualifies the beneficiary for SNF service. Scenario: Stay With Us Nursing Care submitted a claim to Cornerstone Health Care for Mr. Bobst s SNF stay from 5 3 2013 through 5 13 2013. Cornerstone Health Care submitted the encounter to the EDS using OSC 70; however, due to a data entry error, the from and through dates on the encounter were 5 3 2013, indicating a one day service. Edit Edit Description Edit Disposition Comprehensive Resolution Prevention 17085 CC 40 Required for Same Day Transfer Reject Encounters submitted with TOB 11X and a patient status code of 02, 03, 05, 50, 51, 61, 62, 63, 65, 66, | /kaggle/input/edi-db/Jul2016_CG_837I_5CR_081016.pdf | 5d1ff4d3761d8c9adb94936bf1b8ccf5 | 5d1ff4d3761d8c9adb94936bf1b8ccf5_21 |
Subsets and Splits