OP3007 Insured’s Group Number 62A 11 837/2000B/SBR/P/03 (Primary) Insured’s Number 62B 9A 837/2320/SBR/S/03 (Secondary) OP3008 Insured’s Unique Identifier 60A 1A 837/2010BA/NM1/MI/09 (Primary) Insured’s Unique Identifier 60B NA (Secondary) OP3009 Payer Name (Primary) 50A Header/ 837/2010BB/NM1/PR/2/03 Carrier Block Payer Name (Secondary) 50B Header/ 837/2330B/NM1/PR/2/03 Carrier Block HIPAA Reference ASC X12N/005010A1 UB-04 Transaction Set/Loop/ Data Form Segment ID/Code Value/ Element # Data Element Name Locator Reference Designator OP4001 Record Type NA NA NA OP4002 Sequence Number NA NA NA OP4003 Patient Control Number 3A 26 837/2300/CLM/01 OP4004 Type of Bill 4 NA 837/2300/CLM/A/05-1 837/2300/CLM/05-3
OP3007 Insured’s Group Number (Primary) 62A 11 837/2000B/SBR/P/03 Insured’s Number (Secondary) 62B 9A 837/2320/SBR/S/03 OP3008 Insured’s Unique Identifier (Primary) 60A 1A 837/2010BA/NM1/MI/09 Insured’s Unique Identifier (Secondary) 60B NA OP3009 Payer Name (Primary) 50A Header/ Carrier Block 837/2010BB/NM1/PR/2/03 Payer Name (Secondary) 50B Header/ Carrier Block 837/2330B/NM1/PR/2/03 Data Element # Data Element Name UB-04 Form Locator HIPAA Reference ASC X12N/005010A1 Transaction Set/Loop/ Segment ID/Code Value/ Reference Designator OP4001 Record Type NA NA NA OP4002 Sequence Number NA NA NA OP4003 Patient Control Number 3A 26 837/2300/CLM/01 OP4004 Type of Bill 4 NA 837/2300/CLM/A/05-1 837/2300/CLM/05-3
Chapter%20241_20170907_v2.docx