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| # | Location | File | Last Modified |
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| 1 | MCCF.zip\MCCF\docs | eBill+ICD576+v10.00.docx | Thu Apr 13 18:58:04 2017 UTC |
| 2 | MCCF.zip\MCCF\docs | eBill+ICD576+v10.00.docx | Fri Apr 28 18:33:55 2017 UTC |
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| 1 | Medical Ca re Collect ion Fund ( MCCF) eBil ling Compl iance Phas e 4 | |
| 2 | Interface Control Do cument | |
| 3 | Patch IB*2 *576 | |
| 4 | ||
| 5 | Health Car e Claims ( 837) | |
| 6 | ||
| 7 | ||
| 8 | ||
| 9 | ||
| 10 | ||
| 11 | ||
| 12 | ||
| 13 | ||
| 14 | ||
| 15 | ||
| 16 | ||
| 17 | ||
| 18 | Department of Vetera ns Affairs | |
| 19 | January 20 17 | |
| 20 | Version 10 .0 | |
| 21 | ||
| 22 | Revision H istory | |
| 23 | Date | |
| 24 | Version | |
| 25 | Descriptio n | |
| 26 | Author | |
| 27 | 6/10 | |
| 28 | 1.0 | |
| 29 | Existing 8 37 mapping document placed in ICD format | |
| 30 | M. Simons OED | |
| 31 | M. Wilbank s FSC | |
| 32 | 6/18 | |
| 33 | 1.1 | |
| 34 | Modified | |
| 35 | M. Wilbank s FSC | |
| 36 | 8/2/10 | |
| 37 | 1.2 | |
| 38 | Modified: 5.3.1 CL1- 10; 5.3.1 CL1-28 to 30; 5.3.9 PC-04; 5.3 .13; 5.4.1 OI-23 ; 5 .4.1 OI-21 and 22; 5 .4.21 PRF2 1 deleted. ; 5.3.4 SU B 12 | |
| 39 | M. Wilbank s FSC | |
| 40 | 8/5/10 | |
| 41 | 1.3 | |
| 42 | Modified: 5.4.2 OI-7 ; 5.4.21 P RF-5; 5.4. 21 PRF-8 ; 5.4.21 PR F-24; 5.4. 21 PRF-30; 5.4.23 RX 1-7; 5.4.2 3 RX1-8; 6 .5 TOS con version wi ll be remo ved with 5 010. | |
| 43 | M. Wilbank s FSC | |
| 44 | 10/06/10 | |
| 45 | 1.4 | |
| 46 | Modified: 5.2.10 PT2 -5,6; 5.4. 23 RX1-7; 5.3.1 CL1- 5; 5.3.6 U B1-20 | |
| 47 | Deleted: O P6 | |
| 48 | M. Wilbank s FSC | |
| 49 | 10/08/10 | |
| 50 | 1.5 | |
| 51 | Modified: 5.2.3 CI1- 14; 5.2.7 CI5-8; 5.3 .2 CL1A -1 7,19; 5.3. 2 CL1A-23; 5.4.1 OI1 -12; 5.4.2 4 LOPE-16, 17; 5.4.25 LOP1-16,1 7; 5.2.26 LREN-16,17 ; 5.2.28 L SUP-16,17 | |
| 52 | M. Wilbank s FSC | |
| 53 | 10/29/10 | |
| 54 | 1.6 | |
| 55 | Modified: 5.3.1 CL1 CLM05-2 | |
| 56 | M. Wilbank s FSC | |
| 57 | 11/29/10 | |
| 58 | 1.7 | |
| 59 | Added: Max length of all field s | |
| 60 | Modified: 5.2.3 CI1- 14; 5.2.4 CI1A-4; 5. 2.5 CI2 -1 0; 5.2.9 P T1-11; 5.3 .1 CL1-22; 5.3.1 CL1 -23; 5.3.4 SUB-6; 5. 3.18 OPR-1 1; 5.4.20 PRF-5; 5.4 .21 INS-9; 5.4.30 LC OB-6 | |
| 61 | M. Wilbank s FSC | |
| 62 | 1/31/11 | |
| 63 | 1.8 | |
| 64 | Added: 5.2 .2 PRV1-12 | |
| 65 | Modified: CL1-15,17 | |
| 66 | M. Wilbank s FSC | |
| 67 | 3/11 | |
| 68 | 2.0 | |
| 69 | Modified f or Patch I B*2*447 | |
| 70 | T. Zimmer PD | |
| 71 | M. Simons PD | |
| 72 | M. Wilbank s FSC | |
| 73 | 12/13 | |
| 74 | 3.0 | |
| 75 | Modified f or Patch I B*2*488 | |
| 76 | M. Simons | |
| 77 | M. Wilbank s FSC | |
| 78 | A. Sharma FSC | |
| 79 | 1/27/14 | |
| 80 | 4.0 | |
| 81 | Updated fo llowing re view (488) by CBO/PM O | |
| 82 | M. Simons | |
| 83 | A. Sharma FSC | |
| 84 | 3/14 | |
| 85 | 5.0 | |
| 86 | Modified f or Patch I B*2*516 | |
| 87 | Data mappi ng informa tion added | |
| 88 | M. Simons | |
| 89 | M. Wilbank s FSC | |
| 90 | A. Sharma FSC | |
| 91 | 4/14 | |
| 92 | 6.0 | |
| 93 | Updated fo llowing re view (516) by CBO/PM O | |
| 94 | M. Simons | |
| 95 | 5/15 | |
| 96 | 7.0 | |
| 97 | Modified f or Patch I B*2*547 | |
| 98 | M. Simons | |
| 99 | C. Minch | |
| 100 | 6/15 | |
| 101 | 8.0 | |
| 102 | Updated fo r Patch IB *2*547 aft er decisio n to only lengthen l onger insu rance fiel ds – CR 00 2 | |
| 103 | M. Simons | |
| 104 | 4/16 | |
| 105 | 9.0 | |
| 106 | Changes fr om Active state: Gav e BLANK le ngth = 1 | |
| 107 | M.Simons | |
| 108 | 1/17 | |
| 109 | 10.0 | |
| 110 | Updated fo r Patch IB *2*576 | |
| 111 | M. Simons | |
| 112 | Table of C ontents | |
| 113 | 1Introduct ion1 | |
| 114 | 1.1Purpose 1 | |
| 115 | 1.2Scope1 | |
| 116 | 1.3System Identifica tion1 | |
| 117 | 1.3.1Curre nt Claims Process2 | |
| 118 | 1.3.2VistA Integrate d Billing Module3 | |
| 119 | 1.3.3FSC – Gentran B asic3 | |
| 120 | 1.3.4FSC – Instream (HIPAA Val idation So ftware)3 | |
| 121 | 1.4Operati onal Agree ment3 | |
| 122 | 2Interface Definitio n3 | |
| 123 | 2.1System Overview3 | |
| 124 | 2.2Interfa ce Overvie w4 | |
| 125 | 2.3Operati ons4 | |
| 126 | 2.4Data Tr ansfer4 | |
| 127 | 2.5Transac tion Types 4 | |
| 128 | 2.6Data Ex changes4 | |
| 129 | 2.7Communi cations Me thods4 | |
| 130 | 2.8Perform ance Requi rements4 | |
| 131 | 2.9Securit y5 | |
| 132 | 3Interface Requireme nts5 | |
| 133 | 4Interface Verificat ion5 | |
| 134 | 5Appendix A – Data E lements1 | |
| 135 | 5.1Section 1 – Gener al Informa tion1 | |
| 136 | 5.1.1GEN - General I D Data [SE Q 5]2 | |
| 137 | 5.2Section 2 – Per C laim Data3 | |
| 138 | 5.2.1PRV - Loop 2010 AA (Billin g Provider Data) [SE Q 15]3 | |
| 139 | 5.2.2PRV1 - Loop 201 0AB (Pay-T o Provider (Parent V AMC) Data) [SEQ 16]6 | |
| 140 | 5.2.3CI1 - Loop 2010 BB/BC (Cur rent Payer Data) [SE Q 20]8 | |
| 141 | 5.2.4CI1A - Loop 201 0AA (Billi ng Provide r Secondar y ID Data) [SEQ 28]1 1 | |
| 142 | 5.2.5CI2 - Loop 2000 B/2010BA ( Subscriber Data) [SE Q 30]13 | |
| 143 | 5.2.6CI2A - Loop 200 0B/2010BA (Subscribe r Data)15 | |
| 144 | 5.2.7CI3 - Loop 2000 B (Subscri ber Group/ Employment Data) [SE Q 35]17 | |
| 145 | 5.2.8CI3A - Loop 200 0B (Subscr iber Group /Employmen t Data)18 | |
| 146 | 5.2.9CI5 - Loop 2010 BB/BC (Pay er ID Data ) [SEQ 37] 20 | |
| 147 | 5.2.10CI6 - Loop 201 0BA (Subsc riber ID D ata) [SEQ 38]22 | |
| 148 | 5.2.11PT1 - Loop 200 0B/C 2010B A/CA (Pati ent Data) [SEQ 40]24 | |
| 149 | 5.2.12PT2 - Loop 200 0B/C 2010C A (Patient Data) [SE Q45]27 | |
| 150 | 5.3Section 3 – Claim Level Dat a29 | |
| 151 | 5.3.1CL1 - Loop 2300 (Claim Le vel Data) [SEQ 50]29 | |
| 152 | 5.3.2CL1A - Loop 230 0 (Claim L evel Data) [SEQ 51]3 7 | |
| 153 | 5.3.3CL1B – Loop 230 0 (Claim L evel Data) [SEQ 52]4 1 | |
| 154 | 5.3.4SUB - Loop 2310 C/D/E 2300 (Service Facility D ata) [SEQ 55]42 | |
| 155 | 5.3.5SUB2 - Loop 231 0C/E (Serv ice Facili ty Data) [ SEQ 57]45 | |
| 156 | 5.3.6UB1 - Loop 2300 (Claim Le vel Form D ata) [SEQ 60]48 | |
| 157 | 5.3.7OC1-O C12 - Loop 2300 (Occ urrence Co de Data) [ SEQ 65]50 | |
| 158 | 5.3.8OS1-O S12 - Loop 2300 (Occ urrence Sp an Code Da ta) [SEQ 7 0]50 | |
| 159 | 5.3.9PC1-P C12 - Loop 2300 (Pro cedure Cod e Data) [S EQ 75]52 | |
| 160 | 5.3.10SPC- Loop 2300 (Surgical Procedure Code Data ) [SEQ 77 ]53 | |
| 161 | 5.3.11VC1- VC12 - Loo p 2300 (Va lue Code D ata) [SEQ 80]54 | |
| 162 | 5.3.12CC1- CC12 - Loo p 2300 (Co ndition Co de Data) [ SEQ 85]54 | |
| 163 | 5.3.13DC1- DC12 - Loo p 2300 (Di agnosis Co de Data) [ SEQ 90]55 | |
| 164 | 5.3.14OPR - Loop 231 0A/B/C (At t/Other Op er/Oper Ph ysician/Pr ovider Dat a) [SEQ 96 ]56 | |
| 165 | 5.3.15OPR1 - Loop 23 10A/B (Att /Other Ope r/Oper Phy sician/Pro vider Data ) [SEQ 97] 59 | |
| 166 | 5.3.16OPR2 - Loop 23 10A (Atten ding Provi der Second ary ID Dat a) [SEQ 98 ]62 | |
| 167 | 5.3.17OPR3 - Loop 23 10B (Opera ting Physi cian Secon dary ID Da ta) [SEQ 9 9]64 | |
| 168 | 5.3.18OPR4 - Loop 23 10C (Other Operating Provider Secondary ID Data) [ SEQ 100]66 | |
| 169 | 5.3.19OPR5 - Loop 23 10A (Refer ring Provi der Second ary ID Dat a) [SEQ 10 1]70 | |
| 170 | 5.3.20OPR7 - Loop 23 10E (Super vising Pro vider Data ) [SEQ 103 ]73 | |
| 171 | 5.3.21OPR8 - Loop 23 10E (Super vising Pro vider Seco ndary ID D ata) [SEQ 104]75 | |
| 172 | 5.3.22OPR9 – Loop 23 10B/2310D (Rendering Provider Data) [SEQ 104.5]79 | |
| 173 | 5.3.23OPRA – Loop 23 10B/2310D (Rendering Provider Secondary ID) [SEQ 104.4]81 | |
| 174 | 5.3.24AMB - Loop 231 0E/F (Ambu lance Pick -up / Drop -off) [SEQ 104.8]85 | |
| 175 | 5.3.25AMB1 - Loop 23 10E/F (Amb ulance Pic k-up / Dro p-off) [S EQ 104.9]8 7 | |
| 176 | 5.3.26AMB2 - Loop 23 00 (Ambula nce Certif ication Da ta) [SEQ 104.91]88 | |
| 177 | 5.4Section 4 – Other Insurance Data90 | |
| 178 | 5.4.1OI1 - Loop 2320 /2330B (Ot her Subscr iber and O ther Payer Data) [SE Q 105]90 | |
| 179 | 5.4.2OI1A - Loop 232 0/2330B (O ther Subsc riber and Other Paye r Data)93 | |
| 180 | 5.4.3OI2 - Loop 2330 A (Other P ayer Subsc riber Data ) [SEQ 110 ]95 | |
| 181 | 5.4.4OI4 - Loop 2330 B (Other P ayer Data) [SEQ 112] 97 | |
| 182 | 5.4.5OI5 - Loop 2330 A (Other P ayer Subsc riber Data ) [SEQ 113 ]100 | |
| 183 | 5.4.6OI6 - Loop 2330 B (Other P ayer ID Da ta) [SEQ 1 14]103 | |
| 184 | 5.4.7COB1 - Loop 232 0 (Claim L evel COB A mounts) [S EQ 115]106 | |
| 185 | 5.4.8MOA1 - Loop 232 0 (Medicar e Outpatie nt Adjudic ation COB Data) [SEQ 120]107 | |
| 186 | 5.4.9MIA1 - Loop 232 0 (Medicar e Inpatien t Adjudica tion COB D ata) [SEQ 125]109 | |
| 187 | 5.4.10MIA2 - Loop 23 20 (Medica re Inpatie nt Adjudic ation COB Data) [SEQ 130]112 | |
| 188 | 5.4.11CCAS - Loop 23 20 (COB Cl aim Level Adjustment s) [SEQ 13 5]115 | |
| 189 | 5.4.12OP1 - Loop 233 0C/D (Othe r Payer Re ndering Pr ovider Dat a) [SEQ 17 0]120 | |
| 190 | 5.4.13OP1A - Loop 23 30C/D (Oth er Payer A ttending P hysician D ata) [SEQ 170.5]124 | |
| 191 | 5.4.14OP2 - Loop 233 0D (Other Payer Oper ating Phys ician Data ) [SEQ 171 ]127 | |
| 192 | 5.4.15OP3 - Loop 233 0F (Other Payer Serv ice Facili ty Data) [ SEQ 172]13 1 | |
| 193 | 5.4.16OP4 - Loop 233 0C (Other Payer Refe rring Prov ider Data) [SEQ 173] 134 | |
| 194 | 5.4.17OP7 - Loop 233 0E (Other Payer Serv ice Facili ty Data) [ SEQ 176]13 8 | |
| 195 | 5.4.18OP8 - Loop 233 0F (Other Payer Supe rvising Pr ovider Dat a) [SEQ 17 7]141 | |
| 196 | 5.4.19OP9 - Loop 233 0E (Other Payer Othe r Operatin g Provider Data) [SE Q 178]145 | |
| 197 | 5.5Section 5 – Line Level Data 149 | |
| 198 | 5.5.1PRF - Loop 2400 (Professi onal Servi ce Line Da ta) [SEQ 1 80]149 | |
| 199 | 5.5.2RX1 - Loop 2400 /2410 (Dru g Service Line Data) [SEQ 190] 157 | |
| 200 | 5.5.3LDAT – Loop 240 0 Suppleme ntal line informatio n [SEQ 191 ]159 | |
| 201 | 5.5.4LOPE - Loop 242 0A (Line O perating P hysician D ata) [SEQ 192]161 | |
| 202 | 5.5.5LOP1 - Loop 242 0B (Line O ther Opera ting Physi cian Data) [SEQ 193 ]166 | |
| 203 | 5.5.6LREN - Loop 242 0A/C (Line Rendering Provider Data) [SE Q 193.3]17 1 | |
| 204 | 5.5.7LPUR - Loop 242 0B (Line P urchase Se rvice Prov ider Data) [SEQ 193 .6]176 | |
| 205 | 5.5.8LSUP - Loop 242 0D (Line S upervising Provider Data) [SE Q 194]178 | |
| 206 | 5.5.9LREF - Loop 242 0F/D (Line Referring Provider Data) [SE Q 194.3]18 3 | |
| 207 | 5.6Section 6 – Other Insurance Line Leve l Data188 | |
| 208 | 5.6.1LCOB - Loop 243 0 (COB Ser vice Line Adjudicati on Data) [ SEQ 195]18 8 | |
| 209 | 5.6.3LCAS - Loop 243 0 (COB Lin e Level Ad justments) [SEQ 200] 192 | |
| 210 | 6Appendix B – FSC Ma pping Rule s1 | |
| 211 | 6.1TPA Cle aringhouse ID1 | |
| 212 | 6.2Site Fo cus Testin g2 | |
| 213 | 6.3Payer I D Switch3 | |
| 214 | 6.4Set X12 Outbound Claim Vers ion6 | |
| 215 | 6.5Remove NPI from M edicare cl aims7 | |
| 216 | 6.6Remove AB38 | |
| 217 | 6.7Remove LQ9 | |
| 218 | 6.8Remove AAA9 | |
| 219 | 6.9Remove 2U10 | |
| 220 | 6.10Defaul t Service Facility A ddress11 | |
| 221 | 6.11Defaul t Billing Address13 | |
| 222 | 6.12Modify secondary IDs for M edicare Cl aims14 | |
| 223 | 6.13Remove Other Pay er Informa tion from Claim16 | |
| 224 | 6.14Remove Secondary IDs from Claims17 | |
| 225 | 6.15Compar e Subscrib er and Pat ient18 | |
| 226 | 6.16Swap A ddress Lin es19 | |
| 227 | 7Appendix C – FSC De fault Valu es1 | |
| 228 | ||
| 229 | ||
| 230 | ||
| 231 | Introducti on | |
| 232 | This docum ent descri bes the in terface be tween a Vi stA system at a VA M edical Cen ter and th e Gentran system at the VA Fin ancial Ser vices Cent er in Aust in, TX. | |
| 233 | Purpose | |
| 234 | The purpos e of this Interface Control Do cument (IC D) is to d efine the message st ructure an d protocol s which go vern the i nterchange of data b etween the Integrate d Billing (IB) modul e within a VistA sys tem and th e VA Finan cial Servi ces Center (FSC) rel ated to th e electron ic process ing of ASC X12N/0050 10 Health Care Claim s (837). | |
| 235 | Scope | |
| 236 | This Inter face Contr ol Documen t specifie s the inte rface betw een VistA IB and FSC . This doc ument prov ides detai ls on the functional , performa nce, opera tional and design re quirements for the i nterface b etween Vis tA IB and FSC. This document d efines the record la youts for the data t hat the FS C receives from Vist A IB. Thi s document is intend ed for all parties r equiring s uch inform ation, inc luding bus iness stak eholders, end-users, software developers , system d esigners, testers an d anyone e lse respon sible for implementi ng this in terface. | |
| 237 | System Ide ntificatio n | |
| 238 | This Inter face Contr ol Documen t describe s the inte rface betw een VistA IB and the Gentran s ystem at F SC. | |
| 239 | VistA is h ealth care system in stalled at VA Medica l Centers. The IB m odule is s oftware de signed to support th e creation of health care clai ms. This interface supports t he electro nic third party bill ing proces s which in volves the electroni c transmis sion of 83 7 Health C are claims to Emdeon , the VA’s clearingh ouse, wher e claims a re either transmitte d to the i nsurance c ompany or sent to a printing f acility. | |
| 240 | The Gentra n system a t FSC, rec eives the data from a VistA sy stem at a VA Medical Center, t ranslates the data i nto a stan dard ASC X 12N/005010 Health Ca re Claims (837) tran smission, validates whether or not the d ata compli es with HI PAA standa rds and th en forward s the clai m data to Emdeon. | |
| 241 | Current Cl aims Proce ss | |
| 242 | ||
| 243 | VistA Inte grated Bil ling Modul e | |
| 244 | System | |
| 245 | Details | |
| 246 | Title | |
| 247 | VistA Inte grated Bil ling Modul e | |
| 248 | Abbreviati on | |
| 249 | IB | |
| 250 | Version nu mber | |
| 251 | 2 | |
| 252 | Release nu mber | |
| 253 | 576 | |
| 254 | Point of C ontact | |
| 255 | Toby Rudik | |
| 256 | Vendor [op tional] | |
| 257 | n/a | |
| 258 | FSC – Gent ran Basic | |
| 259 | System | |
| 260 | Details | |
| 261 | Title | |
| 262 | Gentran Ba sic | |
| 263 | Abbreviati on | |
| 264 | n/a | |
| 265 | Version nu mber | |
| 266 | 6.5.10 | |
| 267 | Point of C ontact | |
| 268 | Jaime Manz ano | |
| 269 | Vendor [op tional] | |
| 270 | Sterling C ommerce | |
| 271 | FSC – Inst ream (HIPA A Validati on Softwar e) | |
| 272 | System | |
| 273 | Details | |
| 274 | Title | |
| 275 | Instream | |
| 276 | Abbreviati on | |
| 277 | n/a | |
| 278 | Version nu mber | |
| 279 | 7.5.0 | |
| 280 | Point of C ontact | |
| 281 | Jaime Manz ano | |
| 282 | Vendor [op tional] | |
| 283 | TIBCO Soft ware | |
| 284 | Operationa l Agreemen t | |
| 285 | This Inter face Contr ol Documen t provides the speci fication f or an inte rface betw een VistA IB and FSC regarding health ca re claims data. The Chief Busi ness Offic e (CBO) is responsib le for not ifying FSC personnel of any po tential or planned c hanges to data feeds once thes e changes are known in order t o minimize adverse i mpacts. | |
| 286 | Interface Definition | |
| 287 | Health car e claims d ata is tra nsmitted f rom a Vist A system a t a VA Med ical Cente r to the F SC in flat files via VistA Mai lman messa ges. | |
| 288 | Data is al so returne d to the s ending Vis tA system from the F SC in Mail man messag es. Refer to the IC D document X12 835 f ormats for EFT, ERA and MRA da ted May 20 10. | |
| 289 | System Ove rview | |
| 290 | The VistA IB module is designe d to creat e claims f or reimbur sement fro m third pa rty payers for healt h care ser vices rend ered to th e patient by the Dep artment of Vetren’s Affairs wh en the pat ient has p rivate ins urance or is eligibl e for Medi care. The IB softwa re is part of VistA, an integr ated healt h care sys tem, and i s able to create cla ims based on data re ceived fro m the pati ent’s inpa tient and/ or outpati ent patien t record. VistA is a M system with VMS running on Windows. | |
| 291 | Gentran is a COBOL s ystem. It is design to receiv e data fro m a VistA IB system and to tra nslate tha t data int o a HIPAA compliant 837 Health Care Clai m transmis sion. | |
| 292 | Interface Overview | |
| 293 | The messag es exchang ed between VistA and FSC use e xisting Vi stA Mailma n software which rel ies on exi sting TCP/ IP connect ions betwe en the two systems. | |
| 294 | Operations | |
| 295 | Once an IB user auth orizes a t hird party health ca re claim t o a payer who is abl e to recei ve either an electro nic or pri nted claim submissio n, the Vis tA IB modu le will ex tract the claim data and creat e a messag e that wil l be trans mitted at a predeter mined time based upo n site def inable par ameters. The transm ission tim es are def ined in th e IB Site Parameters , [IBJ MCC R SITE PAR AMETERS]. | |
| 296 | A Billing Clerk can force a cl aims trans mission if necessary by using the IB opt ion, [IBCE 837 MANUA L TRANSMIT ] though t his is not normal pr ocedure. | |
| 297 | Whether or not a pay er is able to receiv e claims f rom a HCCH is based upon the c ompany’s a greement w ith the HC CH and ele ctronic pa yers are d efined as such in th e VistA IB option, [ IBCN INSUR ANCE CO ED IT]. | |
| 298 | Claims tha t cannot b e transmit ted to FSC are print ed at the VAMC and m ailed to t he payer. | |
| 299 | Claims are transmitt ed to FSC in batches . | |
| 300 | Data Trans fer | |
| 301 | Data is tr ansferred to and fro m FSC usin g the Vist A Mailman messaging system. | |
| 302 | FSC mainta ins both a test queu e and a pr oduction q ueue. The se queues are define d in the I B Site Par ameters, [ IBJ MCCR S ITE PARAME TERS]. | |
| 303 | Transactio n Types | |
| 304 | VistA tran smits an 8 37 Heath C are Claims transacti on type. Though the messages transmitte d to FSC s till conta in some pr oprietary elements w hich are n eeded by E mdeon to p rint claim s, the mes sage conte nt is mode led on the ASC X12 5 010 standa rd and con tains the data eleme nts necess ary for FS C to creat ed complia nt claims transmissi ons to ele ctronic pa yers. | |
| 305 | Data Excha nges | |
| 306 | VistA tran smits an 8 37 Health Care Claim s transact ion type. Refer to Section Ap pendix A. | |
| 307 | Each line in the Mai lman messa ge will co rrespond t o a record in the 83 7 map. | |
| 308 | Each recor d will beg in with th e record n ame. Each data piece within a record wil l be delim ited by an up caret (^). Each record wil l be termi nated with a tilde ( ~). | |
| 309 | Example: | |
| 310 | PRV ^^CHEY ENNE VAMC^ 2360 E PER SHING BLVD ^CHEYENNE^ WY^8200153 56^3333333 333^830168 494~ | |
| 311 | Each 837 H ealth Care Claims tr ansmission contains a value in the GEN – General I D Data rec ord equiva lent to th e IB Patch version. This valu e allows F SC to rout e incoming 837 Healt h Care Cla im transmi ssion thro ugh the co rrect tran slation ma p at FSC. This allo ws FSC to support Vi stA sites who have d ifferent v ersions of IB*2 inst alled to o perate sim ultaneousl y. | |
| 312 | Communicat ions Metho ds | |
| 313 | Both the F SC and the VistA VAM C systems are config ured to ex change Mai lman messa ges using TCP/IP com munication . | |
| 314 | Performanc e Requirem ents | |
| 315 | No perform ance requi rements ex ist for th e transmis sion of 83 7 Health C are Claim transmissi ons for Vi stA. | |
| 316 | Security | |
| 317 | MailMan tr ansmission between V istA sites and FSC i s within t he VA fire wall. | |
| 318 | Interface Requiremen ts | |
| 319 | Upon autho rization o f a claim to an elec tronically active pa yer (Bill/ Claim File #399), th e VistA sy stem shall extract t he claim d ata and tr ansmit it to FSC in an 837 Hea lth Care C laim trans mission, a t site def ined times , for proc essing by FSC. Refe r to Secti on 2.3. | |
| 320 | Interface Verificati on | |
| 321 | The data t ransmitted to FSC fr om VistA i s validate d in sever al ways: | |
| 322 | Testing da ta will be validated by compar ing what d ata is tra nsmitted t o FSC with what data is receiv ed by FSC | |
| 323 | Testing da ta will be validated by compar ing what d ata is tra nsmitted t o FSC with what data is receiv ed by Emde on | |
| 324 | Testing an d Producti on data wi ll be vali dated for HIPAA comp liance by the Instre am applica tion at FS C | |
| 325 | Testing an d Producti on data wi ll be vali dated for completene ss before being acce pted into the FSC pr eprocessin g software . | |
| 326 | ||
| 327 | ||
| 328 | Appendix A – Data El ements | |
| 329 | This is th e 576 vers ion of thi s document . Changes are in ita licized, r ed text. | |
| 330 | Fields in this docum ent that a re specifi ed as “BLA NK” will h ave a leng th of 1 le aving Vist A (i.e. th e nil stri ng). Howe ver, all o f this dat a is conve rted into a fixed-wi dth file b y FSC. | |
| 331 | A = Alpha A/N = A lpha Numer ic N = Number 2 Decimals = FSC wil l interpre t the numb er as havi ng 2 impli ed decimal points | |
| 332 | Section 1 – General Informatio n | |
| 333 | Section 1 occurs onc e per batc h. This i nformation is not re peated for each clai m. | |
| 334 | BGN - Cont rol Data [ SEQ 1] | |
| 335 | (REQUIRED – Max leng th 6 bytes ) | |
| 336 | Piece | |
| 337 | Descriptio n | |
| 338 | Max Length /Type | |
| 339 | Print/VPE | |
| 340 | FSC Proces sing Comme nts | |
| 341 | 1 | |
| 342 | RECORD ID = ‘BGN ’ | |
| 343 | 4 A | |
| 344 | N/A | |
| 345 | ||
| 346 | 2 | |
| 347 | RECORD DEL IMITER | |
| 348 | 1 A | |
| 349 | N/A | |
| 350 | ||
| 351 | ||
| 352 | GEN - Gene ral ID Dat a [SEQ 5] | |
| 353 | (REQUIRED – Max leng th 84 byte s ) | |
| 354 | Piece | |
| 355 | Descriptio n | |
| 356 | Max Length | |
| 357 | Data Type | |
| 358 | 837/Print Location | |
| 359 | VistA Inpu t/Storage | |
| 360 | FSC Proces sing Comme nts | |
| 361 | 1 | |
| 362 | RECORD ID = ‘GEN ’ | |
| 363 | 4 A | |
| 364 | ||
| 365 | ||
| 366 | ||
| 367 | 2 | |
| 368 | VISTA INTE RNAL CONTR OL NUMBER | |
| 369 | 10 NUM | |
| 370 | ||
| 371 | ||
| 372 | ||
| 373 | 3 | |
| 374 | DATE | |
| 375 | 8 NUM CCYY MMDD | |
| 376 | BHT04 | |
| 377 | ||
| 378 | ||
| 379 | 4 | |
| 380 | REFERENCE # | |
| 381 | 10 NUM | |
| 382 | BHT03 | |
| 383 | ||
| 384 | ||
| 385 | 5 | |
| 386 | SITE ID | |
| 387 | 3 A/N | |
| 388 | ||
| 389 | ||
| 390 | ||
| 391 | 6 | |
| 392 | RECEIVER I D # | |
| 393 | ENVOYH (En voy hospit al) | |
| 394 | ENVOYP (En voy Profes sional) | |
| 395 | CHAMVA (Ch ampVA bill s) | |
| 396 | PARTA (MED ICARE PART A) (Insti tutional) | |
| 397 | PARTB (MED ICARE PART B) (Profe ssional) | |
| 398 | 30 A/N | |
| 399 | ||
| 400 | ID’s ENVOY H, ENVOYP and CHAMVH , CHAMVP | |
| 401 | ||
| 402 | ||
| 403 | 7 | |
| 404 | VERSION ID ENTIFIER | |
| 405 | 13 A/N | |
| 406 | ||
| 407 | ||
| 408 | 576 | |
| 409 | For testin g purposes , the 11th character is “D” | |
| 410 | ||
| 411 | Section 2 – Per Clai m Data | |
| 412 | Section 2 occurs onc e per clai m. | |
| 413 | PRV - Loop 2010AA (B illing Pro vider Data ) [SEQ 15] | |
| 414 | 5010: The Billing Pr ovider Loo p must be a provider facility and also t he lowest enumerated NPI of th e provider . Billing Provider identifier s have cha nged. The NPI is no w the only allowed i dentifier in the 201 0AA NM109 data eleme nt. | |
| 415 | (REQUIRED – Max len gth 206 b ytes) | |
| 416 | Piece | |
| 417 | Descriptio n | |
| 418 | Max Length Data Type | |
| 419 | 837/Print Location | |
| 420 | VistA Inpu t/Storage | |
| 421 | FSC Proces sing Comme nts | |
| 422 | 1 | |
| 423 | RECORD ID = ‘PRV ’ | |
| 424 | 4 A | |
| 425 | ||
| 426 | ||
| 427 | ||
| 428 | 2 | |
| 429 | BLANK | |
| 430 | 1 | |
| 431 | ||
| 432 | ||
| 433 | ||
| 434 | 3 | |
| 435 | Billing Pr ov Organiz ation Name | |
| 436 | 30 A | |
| 437 | 837: 2010A A NM103 | |
| 438 | Print: | |
| 439 | CMS 1500 – Box 33 – Line 1 | |
| 440 | UB04 – FL1 – Line 1 | |
| 441 | Biller Inp ut: N/A | |
| 442 | Screen 10, Section 5 or 7 | |
| 443 | The Billin g Provider is calcul ated based on the di vision. I f the divi sion has n o NPI then the paren t division is used. For RX cl aims, the dispensing pharmacy is used. | |
| 444 | Storage: | |
| 445 | File – Ins titution ( #4) | |
| 446 | Field – BI LLING FACI LITY NAME (# 200) el se NAME (# .01) | |
| 447 | Maximum HI PAA length is 60. | |
| 448 | Set NM101 = 85 | |
| 449 | NM102 =2 | |
| 450 | 4 | |
| 451 | Billing Pr ov Address 1 | |
| 452 | 35 A/N | |
| 453 | 837: 2010A A N301 | |
| 454 | Print: | |
| 455 | CMS 1500 – Box 33 – Line 2 | |
| 456 | UB04 – FL1 – Line 2 | |
| 457 | Biller Inp ut: N/A | |
| 458 | Storage: F ile – Inst itution (# 4) | |
| 459 | Field – 1.01 | |
| 460 | Field 1.01 – STREET ADDR. 1 | |
| 461 | ||
| 462 | 5 | |
| 463 | Billing Pr ov City Na me | |
| 464 | 30 A/N | |
| 465 | 837: 2010A A N401 | |
| 466 | Print: | |
| 467 | CMS 1500 – Box 33 – Line 3 | |
| 468 | UB04 – FL1 – Line 3 | |
| 469 | Biller Inp ut: N/A | |
| 470 | Storage: | |
| 471 | File – Ins titution ( #4) | |
| 472 | Field – C ITY (#1.03 ) | |
| 473 | ||
| 474 | 6 | |
| 475 | Billing Pr ov State C ode | |
| 476 | 2 A/N | |
| 477 | 837: 2010A A N402 | |
| 478 | Print: | |
| 479 | CMS 1500 – Box 33 – Line 3 | |
| 480 | UB04 – FL1 – Line 3 | |
| 481 | Biller Inp ut: N/A | |
| 482 | Storage: | |
| 483 | File – Ins titution ( #4) | |
| 484 | Field – ST ATE (#.02) | |
| 485 | Required w hen in US or territo ries. | |
| 486 | 7 | |
| 487 | Billing Pr ov ZIP Cod e | |
| 488 | 9 N | |
| 489 | 837: 2010A A N403 | |
| 490 | Print: | |
| 491 | CMS 1500 – Box 33 – Line 3 | |
| 492 | UB04 – FL1 – Line 3 | |
| 493 | Biller Inp ut: N/A | |
| 494 | Storage: | |
| 495 | File – Ins titution ( #4) | |
| 496 | Field – ZI P (# 1.04) | |
| 497 | Required w hen in US or territo ries. | |
| 498 | 8 | |
| 499 | Communicat ion Number (Phone) | |
| 500 | ||
| 501 | 20 A?N | |
| 502 | 837: 2010A A PER04 | |
| 503 | Print: | |
| 504 | CMS 1500 – Box 33 - Top | |
| 505 | UB04 – FL1 – Line 4 | |
| 506 | Biller Inp ut: N/A | |
| 507 | IB Site Pa rameters S ection 10 | |
| 508 | The teleph one number is the nu mber defin ed in Sect ion 10 of the IB Sit e Paramete rs for the Pay-to Pr ovider for the divis ion used f or the Bil ling Provi der. | |
| 509 | Storage: | |
| 510 | File - IB SITE PARAM ETERS (#350.9) | |
| 511 | Sub-file – Pay-to Pr oviders | |
| 512 | Field - TE LEPHONE NU MBER (#.04 ) | |
| 513 | Set PER01 = 1C | |
| 514 | PER03 = TE | |
| 515 | Maximum HI PAA length is 256. | |
| 516 | 9 | |
| 517 | Billing Pr ov Primary ID | |
| 518 | 17 A/N | |
| 519 | 837: 2010A A NM109 | |
| 520 | Print: | |
| 521 | CMS 1500 – Box 33a | |
| 522 | UB04 – FL5 6 - NPI | |
| 523 | Biller Inp ut: N/A | |
| 524 | This is th e Billing Provider’s NPI. | |
| 525 | Storage: | |
| 526 | File – INS TITUTION ( #4) | |
| 527 | Field – NP I (#41.99) | |
| 528 | ||
| 529 | 10 | |
| 530 | BLANK | |
| 531 | 1 | |
| 532 | ||
| 533 | ||
| 534 | ||
| 535 | 11 | |
| 536 | Billing Pr ov Address 2 | |
| 537 | 30 A/N | |
| 538 | 837: 2010A A N302 | |
| 539 | Print: | |
| 540 | UB04 - FL1 – Line 2 | |
| 541 | Biller Inp ut: N/A. | |
| 542 | Storage: | |
| 543 | File – INS TITUTION ( #4) | |
| 544 | Field – ST REET ADDR. 2 (#1.02) | |
| 545 | . | |
| 546 | Maximum HI PAA length increased to 55. | |
| 547 | 12 | |
| 548 | Billing Pr ovider Pri mary ID Qu alifier | |
| 549 | 2 A | |
| 550 | 837: 2010A A NM108 | |
| 551 | Print: N/A | |
| 552 | Biller Inp ut: N/A | |
| 553 | Storage: N /A | |
| 554 | Note: Alwa ys XX | |
| 555 | ||
| 556 | 13 | |
| 557 | Billing Pr ov Taxonom y Code Qua lifier | |
| 558 | 2 A | |
| 559 | 837: 2000A PRV01 | |
| 560 | Print: | |
| 561 | CMS 1500 – Box 33b – Other IDs may take precedence | |
| 562 | Biller Inp ut: N/A | |
| 563 | Storage: N /A | |
| 564 | Note: Alwa ys BI | |
| 565 | ||
| 566 | 14 | |
| 567 | Billing Pr ov Taxonom y Code | |
| 568 | 10 A/N | |
| 569 | 837: 2000A PRV03 | |
| 570 | Print: N/A | |
| 571 | ||
| 572 | Biller Inp ut: | |
| 573 | Screen 10, Section 5 or 7 | |
| 574 | The Billin g Provider Taxonomy Code will be automat ically pop ulated but a user ma y override the defau lt value. | |
| 575 | Storage: | |
| 576 | File – INS TITUTION ( #4) | |
| 577 | Subfile: T AXONOMY (# 43) | |
| 578 | Field – TA XONONY COD E (#.01) | |
| 579 | Set PRV02 = PXC | |
| 580 | ||
| 581 | ||
| 582 | PRV1 - Loo p 2010AB ( Pay-To Pro vider (Par ent VAMC) Data) [SEQ 16] | |
| 583 | (REQUIRED – Max le ngth 138 b ytes) | |
| 584 | Piece | |
| 585 | Descriptio n | |
| 586 | Max Length | |
| 587 | Data Type | |
| 588 | 837/Print Location | |
| 589 | VistA Inpu t/Storage | |
| 590 | FSC Proces sing Comme nts | |
| 591 | 1 | |
| 592 | RECORD ID = ‘PRV1' | |
| 593 | 4 A | |
| 594 | ||
| 595 | ||
| 596 | . | |
| 597 | 2 | |
| 598 | Entity ID Code "87" | |
| 599 | 2 N | |
| 600 | 837: 2010A B NM101 | |
| 601 | Print: N/A | |
| 602 | Biller Inp ut: N/A | |
| 603 | Storage: N /A | |
| 604 | . | |
| 605 | 3 | |
| 606 | Entity Typ e Qualifie r "2" | |
| 607 | 1 N | |
| 608 | 837: 2010A B NM102 | |
| 609 | Print: N/A | |
| 610 | Biller Inp ut: N/A | |
| 611 | Storage: N /A | |
| 612 | . | |
| 613 | 4 | |
| 614 | BLANK | |
| 615 | 1 | |
| 616 | ||
| 617 | ||
| 618 | ||
| 619 | 5 | |
| 620 | BLANK | |
| 621 | 1 | |
| 622 | ||
| 623 | ||
| 624 | ||
| 625 | 6 | |
| 626 | BLANK | |
| 627 | 1 | |
| 628 | ||
| 629 | ||
| 630 | ||
| 631 | 7 | |
| 632 | Pay-To Pro v Address 1 | |
| 633 | 35 A/N | |
| 634 | 837: 2010A B N301 | |
| 635 | Print: | |
| 636 | CMS 1500 – Box 33 – Line 2 | |
| 637 | UB04 – FL2 - Line 2 | |
| 638 | Note: FL2 will not b e populate d if the P ay-to Prov ider infor mation is exactly th e same as the Billin g Provider . | |
| 639 | Biller Inp ut: N/A | |
| 640 | Section 10 | |
| 641 | The Pay-to Provider Address is defined i n Section 10/11 of t he IB Site Parameter s for the Pay-to Pro vider for the divisi on used as the Billi ng Provide r. | |
| 642 | Storage: | |
| 643 | File - IB SITE PARAM ETERS (#350.9) | |
| 644 | Sub-file – Pay-to Pr oviders | |
| 645 | Field – ST REET ADDRE SS 1 (#1.0 1) | |
| 646 | ||
| 647 | ||
| 648 | 8 | |
| 649 | Pay-To Pro v Address 2 | |
| 650 | 35 A/N | |
| 651 | 837: 2010A B N302 | |
| 652 | Print: | |
| 653 | CMS 1500 – Box 33 – Line 2 | |
| 654 | UB04 – FL 2 – Line 2 | |
| 655 | Note: FL2 will not b e populate d if the P ay-to Prov ider infor mation is exactly th e same as the Billin g Provider . | |
| 656 | ||
| 657 | Biller Inp ut: N/A | |
| 658 | Section 10 | |
| 659 | The Pay-to Provider Address is defined i n Section 10/11 of t he IB Site Parameter s for the Pay-to Pro vider for the divisi on used as the Billi ng Provide r. | |
| 660 | Storage: | |
| 661 | File - IB SITE PARAM ETERS (#350.9) | |
| 662 | Sub-file – Pay-to Pr oviders | |
| 663 | Field – ST REET ADDRE SS 2 (#1.0 2) | |
| 664 | Maximum HI PAA length is 55. | |
| 665 | 9 | |
| 666 | Pay-To Pro v City Nam e | |
| 667 | 30 A/N | |
| 668 | 837: 2010A B N401 | |
| 669 | Print: | |
| 670 | CMS 1500 – Box 33 – Line 3 | |
| 671 | UB04 – FL2 – Line 3 | |
| 672 | Note: FL2 will not b e populate d if the P ay-to Prov ider infor mation is exactly th e same as the Billin g Provider . | |
| 673 | Biller Inp ut: N/A | |
| 674 | Section 10 | |
| 675 | The Pay-to Provider Address is defined i n Section 10/11 of t he IB Site Parameter s for the Pay-to Pro vider for the divisi on used as the Billi ng Provide r. | |
| 676 | Storage: | |
| 677 | File - IB SITE PARAM ETERS (#350.9) | |
| 678 | Sub-file – Pay-to Pr oviders | |
| 679 | Field – CI TY (#1.03) | |
| 680 | ||
| 681 | 10 | |
| 682 | Pay-To Pro v State Co de | |
| 683 | 2 A/N | |
| 684 | 837: 2010A B N402 | |
| 685 | Print: | |
| 686 | CMS 1500 – Box 33 – Line 3 | |
| 687 | UB04 – FL2 – Line 3 | |
| 688 | Note: FL2 will not b e populate d if the P ay-to Prov ider infor mation is exactly th e same as the Billin g Provider . | |
| 689 | Biller Inp ut: N/A | |
| 690 | Section 10 | |
| 691 | The Pay-to Provider Address is defined i n Section 10/11 of t he IB Site Parameter s for the Pay-to Pro vider for the divisi on used as the Billi ng Provide r. | |
| 692 | Storage: | |
| 693 | File - IB SITE PARAM ETERS (#350.9) | |
| 694 | Sub-file – Pay-to Pr oviders | |
| 695 | Field – ST ATE (#1.04 ) | |
| 696 | ||
| 697 | 11 | |
| 698 | Pay-To Pro v ZIP Code | |
| 699 | 15 N | |
| 700 | 837: 2010A B N403 | |
| 701 | Print: | |
| 702 | CMS 1500 – Box 33 – Line 3 | |
| 703 | UB04 – FL2 – Line 3 | |
| 704 | Note: FL2 will not b e populate d if the P ay-to Prov ider infor mation is exactly th e same as the Billin g Provider . | |
| 705 | Biller Inp ut: N/A | |
| 706 | Section 10 | |
| 707 | The Pay-to Provider Address is defined i n Section 10/11 of t he IB Site Parameter s for the Pay-to Pro vider for the divisi on used as the Billi ng Provide r. | |
| 708 | Storage: | |
| 709 | File - IB SITE PARAM ETERS (#350.9) | |
| 710 | Sub-file – Pay-to Pr oviders | |
| 711 | Field – ZI P (#1.05) | |
| 712 | ||
| 713 | ||
| 714 | CI1 - Loop 2010BB/BC (Current Payer Data ) [SEQ 20] | |
| 715 | (REQUIRED – Max len gth 174 b ytes) | |
| 716 | Piece | |
| 717 | Descriptio n | |
| 718 | Max Length | |
| 719 | Data Type | |
| 720 | 837/Print Location | |
| 721 | VistA Inpu t/Storage | |
| 722 | FSC Proces sing Comme nts | |
| 723 | 1 | |
| 724 | RECORD ID = ‘CI1 ’ | |
| 725 | 4 A | |
| 726 | ||
| 727 | ||
| 728 | ||
| 729 | 2 | |
| 730 | Payer Name | |
| 731 | 30 A/N | |
| 732 | 837: | |
| 733 | (I) 2010BB NM103 | |
| 734 | (P) 2010BB NM103 | |
| 735 | Print: | |
| 736 | CMS 1500 – Top of fo rm – Line 2 | |
| 737 | UB04 – FL3 8 – Line 1 | |
| 738 | UB04 – FL5 0 | |
| 739 | ||
| 740 | ||
| 741 | Biller Inp ut: Screen 3 Section 1 | |
| 742 | The payer is added t o a bill o n screen 3 but the p ayer must already ex ist. | |
| 743 | Payers are defined i n Insuranc e Company Entry/Edit . Insuran ce is ente red for a specific p atient in Patient In surance In fo Add/Edi t. Once t he insuran ce policy exists for a patient , it may b e added to a bill an d the syst em knows t o which in surance co mpany the patient’s policy bel ongs.. | |
| 744 | Storage: | |
| 745 | File - Ins urance Com pany (#36) | |
| 746 | Field – Na me (#.01) | |
| 747 | ||
| 748 | Maximum HI PAA length is 60. | |
| 749 | Set NM101 = PR | |
| 750 | NM102 = 2 | |
| 751 | 837I Loop change fro m 2010BC t o 2010BB | |
| 752 | 3 | |
| 753 | Payer Addr ess 1 | |
| 754 | 35 A/N | |
| 755 | 837: | |
| 756 | (I) 2010BB N301 | |
| 757 | (P) 2010BB N301 | |
| 758 | Print: | |
| 759 | CMS 1500 – Top of fo rm – Line 3 | |
| 760 | UB04 – FL3 8 – Line 2 | |
| 761 | ||
| 762 | Note: Medi care (WNR) requires no Mailing Address o n Screen 3 or in the 837 | |
| 763 | Biller Inp ut: Scree n 3 Sectio n 3 | |
| 764 | The payer address wi ll be pull ed automat ically fro m the Insu rance Comp any File b ut a user may overri de the def ault answe r. There are addres ses for Ma iling/Inpt /Outpt/RX/ Inquiry an d Appeals claims. T he claim t ype and/or the avail ability of the diffe rent addre sses will affect the default v alue. | |
| 765 | Storage: | |
| 766 | File - Ins urance Com pany (#36) | |
| 767 | Field – Ad dress Line 1 (#.111, .121, .14 1, .151, . 161, .181) | |
| 768 | 837I Loop change fro m 2010BC t o 2010BB | |
| 769 | 4 | |
| 770 | Payer City Name | |
| 771 | 30 A/N | |
| 772 | 837: | |
| 773 | (I) 2010BB N301 | |
| 774 | (P) 2010BB N301 | |
| 775 | Print: | |
| 776 | CMS 1500 – Top of fo rm – Line 5 | |
| 777 | UB04 – FL3 8 – Line 3 | |
| 778 | Biller Inp ut: Scree n 3 Sectio n 3 | |
| 779 | Storage: | |
| 780 | File - Ins urance Com pany (#36) | |
| 781 | Field – CI TY (#.114, .124, .14 4, .154, . 164, .184) | |
| 782 | 837I Loop change fro m 2010BC t o 2010BB | |
| 783 | 5 | |
| 784 | Payer Stat e Code | |
| 785 | 2 A/N | |
| 786 | 837: | |
| 787 | (I) 2010BB N301 | |
| 788 | (P) 2010BB N301 | |
| 789 | Print: | |
| 790 | CMS 1500 – Top of fo rm – Line 5 | |
| 791 | UB04 – FL3 8 – Line 3 | |
| 792 | Biller Inp ut: Scree n 3 Sectio n 3 | |
| 793 | Storage: | |
| 794 | File - Ins urance Com pany (#36) | |
| 795 | Field – ST ATE (#.115 , .125, .1 45, .155, .165, .185 ) | |
| 796 | Required w hen in US or territo ries. | |
| 797 | 837I Loop change fro m 2010BC t o 2010BB | |
| 798 | 6 | |
| 799 | Payer ZIP Code | |
| 800 | 15 NUM | |
| 801 | 837: | |
| 802 | (I) 2010BB N301 | |
| 803 | (P) 2010BB N301 | |
| 804 | Print: | |
| 805 | CMS 1500 – Top of fo rm – Line 5 | |
| 806 | UB04 – FL3 8 – Line 3 | |
| 807 | Biller Inp ut: Scree n 3 Sectio n 3 | |
| 808 | Storage: | |
| 809 | File - Ins urance Com pany (#36) | |
| 810 | Field – ZI P (#.116, .126, .146 , .156, .1 66, .186) | |
| 811 | Required w hen in US or territo ries. | |
| 812 | 837I Loop change fro m 2010BC t o 2010BB | |
| 813 | 7 | |
| 814 | BLANK | |
| 815 | 1 | |
| 816 | ||
| 817 | ||
| 818 | ||
| 819 | 8 | |
| 820 | BLANK | |
| 821 | 1 | |
| 822 | ||
| 823 | ||
| 824 | ||
| 825 | 9 | |
| 826 | BLANK | |
| 827 | 1 | |
| 828 | ||
| 829 | ||
| 830 | ||
| 831 | 10 | |
| 832 | Payer Addr ess 2 | |
| 833 | 35 A/N | |
| 834 | 837: | |
| 835 | (I) 2010BB N301 | |
| 836 | (P) 2010BB N301 | |
| 837 | Print: | |
| 838 | CMS 1500 – Top of fo rm – Line 4 | |
| 839 | UB04 – FL3 8 – Line 2 | |
| 840 | Biller Inp ut: Scree n 3 Sectio n 3 | |
| 841 | Storage: | |
| 842 | File - Ins urance Com pany (#36) | |
| 843 | Field – Ci ty (#.112, .122, .14 2, .152, . 162, .182) | |
| 844 | 837I Loop change fro m 2010BC t o 2010BB | |
| 845 | 11 | |
| 846 | BLANK | |
| 847 | 1 | |
| 848 | ||
| 849 | ||
| 850 | ||
| 851 | 12 | |
| 852 | Insurance Type Code | |
| 853 | 2 A/N | |
| 854 | 837: (P) 2 000B SBR05 | |
| 855 | Print: | |
| 856 | CMS 1500 – Box 1 – C heck Box | |
| 857 | Note: Vist A looks at the Elect ronic Plan Type of t he Group I nsurance P lan file ( #355.3) an d checks M edicare, M edicaid or TRICARE i f appropri ate. If no t it, Vist A checks t he bill to see if it is reimbu rsable and if the ra te type (# 399.3) is CHAMPVA, c hecks the CHAMPVA bo x. If not, it checks the Insur ance Compa ny file (# 36) to see if the El ectronic I nsurance T ype is Gro up Policy and checks the Group box. Vist A never ch ecks the F ECA BLK Lu ng box, an d if none of the abo ve conditi ons exist, VistA che cks the Ot her box. | |
| 858 | Biller Inp ut: N/A | |
| 859 | VistA look s at the E lectronic Plan Type of the Gro up Insuran ce Plan. | |
| 860 | Storage: | |
| 861 | File: GROU P INSURANC E PLAN (#3 55.3) | |
| 862 | Field: ELE CTRONIC PL AN TYPE (# .15) | |
| 863 | ||
| 864 | 13 | |
| 865 | BLANK | |
| 866 | 1 | |
| 867 | ||
| 868 | ||
| 869 | ||
| 870 | 14 | |
| 871 | BLANK | |
| 872 | 1 | |
| 873 | ||
| 874 | ||
| 875 | ||
| 876 | 15 | |
| 877 | MRA Second ary Indica tor | |
| 878 | 1 A | |
| 879 | 837: N/A | |
| 880 | Print: N/A | |
| 881 | ||
| 882 | Note: M - MRA second ary N - no n-MRA seco ndary Blan k - primar y claim. | |
| 883 | Biller Inp ut: N/A | |
| 884 | Storage: | |
| 885 | File: BILL /CLAIM (#3 99) | |
| 886 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 887 | ||
| 888 | ||
| 889 | ||
| 890 | CI1A - Loo p 2010AA ( Billing Pr ovider Sec ondary ID Data) [SEQ 28] | |
| 891 | (REQUIRED – Max len gth 92 byt es) | |
| 892 | Piece | |
| 893 | Descriptio n | |
| 894 | Max Length | |
| 895 | Data Type | |
| 896 | 837/Print Location | |
| 897 | VistA Inpu t/Storage | |
| 898 | FSC Proces sing Comme nts | |
| 899 | 1 | |
| 900 | RECORD ID = ‘CI1A ’ | |
| 901 | 4 A | |
| 902 | ||
| 903 | ||
| 904 | ||
| 905 | 2 | |
| 906 | Billing Pr ov Sec ID Qualifier( 1) | |
| 907 | 2 A/N | |
| 908 | 837: 2010A A REF01 | |
| 909 | Print: N/A | |
| 910 | Biller Inp ut: N/A | |
| 911 | Storage: N /A | |
| 912 | Note: Alwa ys G5 | |
| 913 | Non-HIPAA Emdeon req uirement. | |
| 914 | 3 | |
| 915 | Billing Pr ov Sec ID( 1) | |
| 916 | (4 charact er Site/Di v ID for r eport sort ing) | |
| 917 | 20 A/N | |
| 918 | 837: 2010A A REF02 | |
| 919 | Print: N/A | |
| 920 | Emdeon use s this ID to sort re ports to t he sites. | |
| 921 | Biller Inp ut: N/A | |
| 922 | Storage: | |
| 923 | File: INST ITUTION (# 4) | |
| 924 | Field: NAM E (#.01) | |
| 925 | See note a bove. Emde on site ID | |
| 926 | 4 | |
| 927 | Billing Pr ov Sec ID Qualifier( 2) | |
| 928 | 2 A/N | |
| 929 | ||
| 930 | ||
| 931 | 837: 2010A A REF01 | |
| 932 | Print: | |
| 933 | CMS 1500 – Box 33b | |
| 934 | ||
| 935 | Biller Inp ut: Screen 3 Section 2 | |
| 936 | Biller’s m ay overrid e the defa ult value on Screen 3 Section 2 | |
| 937 | Storage: | |
| 938 | File: FACI LITY BILLI NG ID (#35 5.92) | |
| 939 | Field: PRO VIDER ID ( #.07) | |
| 940 | 837I Must be EI | |
| 941 | 837P MUST EI | |
| 942 | 5 | |
| 943 | Billing Pr ov Sec ID( 2) | |
| 944 | 20 A/N | |
| 945 | 837: 2010A A REF02 | |
| 946 | Print: | |
| 947 | CMS 1500 – Box 33b | |
| 948 | UB04 – FL5 7 | |
| 949 | ||
| 950 | Note: If n o Billing Provider S econdary I D is defin ed, VistA will use t he site’s Tax ID. | |
| 951 | Biller Inp ut: Screen 3 Section 2 | |
| 952 | Billing Pr ovider Sec ondary IDs are defin ed in Insu rance Comp any Entry/ EditProvid er IDs/ID Param. Th ey are def ined by Di vision and Form Type . The main division can act as the defau lt for all divisions . The qua lifiers ca n be speci fically de fine (i.e. 1B for BS ) or set t o Electron ic Plan Ty pe and the patient’s Plan Type will dete rmine the qualifier. | |
| 953 | The Billin g Provider Secondary ID may al so be setu p in Insur ance Compa ny Entry/E dit to use the Atten ding/Rende ring provi der’s ID a s the Bill ing Provid er Seconda ry ID. | |
| 954 | Biller’s m ay overrid e the defa ult value on Screen 3 Section 2. | |
| 955 | Storage: | |
| 956 | File: FACI LITY BILLI NG ID (#35 5.92) | |
| 957 | Field: PRO VIDER ID ( #.07) | |
| 958 | Must be EI N for Inst itutional. | |
| 959 | Must be EI N for Prof essional. | |
| 960 | 6 | |
| 961 | Billing Pr ov Sec ID Qualifier( 3) | |
| 962 | 2 A/N | |
| 963 | 837: | |
| 964 | (P) 2010AA REF01 | |
| 965 | (P and I) 2010BB REF 01 | |
| 966 | Print: N/A | |
| 967 | Biller Inp ut: Screen 3 Section 2 | |
| 968 | Biller’s m ay overrid e the defa ult value on Screen 3 Section 2 | |
| 969 | Storage: | |
| 970 | File: FACI LITY BILLI NG ID (#35 5.92) | |
| 971 | Field: PRO VIDER ID ( #.07) | |
| 972 | 2010AA Mus t be 0B St ate licens e number o r 1G UPIN number | |
| 973 | 2010BB Mus t be G2 or LU use on ly if PRV9 (Billing provider N PI) is nul l | |
| 974 | 7 | |
| 975 | Billing Pr ov Sec ID( 3) | |
| 976 | 20 A/N | |
| 977 | 837: 2010A A REF02 | |
| 978 | Print: | |
| 979 | UB04 – FL5 7 | |
| 980 | Biller Inp ut: Screen 3 Section 2 | |
| 981 | Additional Billing P rovider Se condary ID s are defi ned in Ins urance Com pany Entry /EditProvi der IDs/ID ParamAddi tional IDs | |
| 982 | Biller’s m ay overrid e the defa ult value on Screen 3 Section 2. | |
| 983 | Storage: | |
| 984 | File: FACI LITY BILLI NG ID (#35 5.92) | |
| 985 | Field: PRO VIDER ID ( #.07) | |
| 986 | 2010BB use only if P RV9 (Billi ng provide r NPI) is null | |
| 987 | 8 | |
| 988 | Billing Pr ov Sec ID Qualifier( 4) | |
| 989 | 2 A/N | |
| 990 | 837: 2010A A REF01 | |
| 991 | Print: N/A | |
| 992 | ||
| 993 | Biller Inp ut: Screen 3 Section 2 | |
| 994 | Biller’s m ay overrid e the defa ult value on Screen 3 Section 2 | |
| 995 | Storage: | |
| 996 | File: FACI LITY BILLI NG ID (#35 5.92) | |
| 997 | Field: PRO VIDER ID ( #.07) | |
| 998 | Must be 0B State lic ense numbe r or 1G UP IN number | |
| 999 | 837I eleme nt deleted | |
| 1000 | 9 | |
| 1001 | Billing Pr ov Sec ID( 4) | |
| 1002 | 20 A/N | |
| 1003 | 837: 2010A A REF02 | |
| 1004 | Print: | |
| 1005 | UB04 – FL5 7 | |
| 1006 | Biller Inp ut: Screen 3 Section 2 | |
| 1007 | Additional Billing P rovider Se condary ID s are defi ned in Ins urance Com pany Entry /EditProvi der IDs/ID ParamAddi tional IDs | |
| 1008 | Biller’s m ay overrid e the defa ult value on Screen 3 Section 2. | |
| 1009 | Storage: | |
| 1010 | File: FACI LITY BILLI NG ID (#35 5.92) | |
| 1011 | Field: PRO VIDER ID ( #.07) | |
| 1012 | 837I eleme nt deleted | |
| 1013 | ||
| 1014 | CI2 - Loop 2000B/201 0BA (Subsc riber Data ) [SEQ 30] | |
| 1015 | (REQUIRED – Max len gth 151 by tes) | |
| 1016 | Piece | |
| 1017 | Descriptio n | |
| 1018 | Max Length | |
| 1019 | Data Type | |
| 1020 | 837/Print Location | |
| 1021 | VistA Inpu t/Storage | |
| 1022 | FSC Proces sing Comme nts | |
| 1023 | 1 | |
| 1024 | RECORD ID = ‘CI2 ’ | |
| 1025 | 4 A | |
| 1026 | ||
| 1027 | ||
| 1028 | ||
| 1029 | 2 | |
| 1030 | Payer Resp onsibility Sequence | |
| 1031 | 1 A | |
| 1032 | 837: 2000B SBR01 | |
| 1033 | Print: N/A | |
| 1034 | Biller Inp ut: Screen 3 Section 1 | |
| 1035 | Storage: | |
| 1036 | File: BILL /CLAIM (#3 99) | |
| 1037 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 1038 | Codes adde d to indic ate sequen ce out to 11 payers. VHA will only use u p to three payers by VHA. | |
| 1039 | 3 | |
| 1040 | Subscriber Last Name | |
| 1041 | 60 A/N | |
| 1042 | 837: 2010B A NM103 | |
| 1043 | Print: | |
| 1044 | CMS 1500 – Box 4 | |
| 1045 | Box 13 – S ignature B lock | |
| 1046 | UB04 – FL5 8 by Payer | |
| 1047 | Biller Inp ut: N/A | |
| 1048 | Screen 3 S ection 1 | |
| 1049 | The biller can add t he patient ’s insuran ce policy to the bil l on Scree n 3 Sectio n 1. The Subscriber informati on is main tained in Patient In surance In fo View/Ed itAdd Poli cy or Poli cy View/Ed itSubscrib er Updates | |
| 1050 | Storage: | |
| 1051 | File: PATI ENT (#2) | |
| 1052 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1053 | Field: NAM E OF INSUR ED (#17) | |
| 1054 | Maximum HI PAA length is 60. | |
| 1055 | Set NM101 = IL | |
| 1056 | NM102 = 1 | |
| 1057 | 4 | |
| 1058 | Subscriber First Nam e | |
| 1059 | 35 A/N | |
| 1060 | 837: 2010B A NM104 | |
| 1061 | Print: | |
| 1062 | CMS 1500 – Box 4 | |
| 1063 | Box 13 – S ignature B lock | |
| 1064 | UB04 – FL5 8 by Payer | |
| 1065 | Biller Inp ut: N/A | |
| 1066 | Screen 3 S ection 1 | |
| 1067 | Storage: | |
| 1068 | File: PATI ENT (#2) | |
| 1069 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1070 | Field: NAM E OF INSUR ED (#17) | |
| 1071 | Maximum HI PAA length is 35. | |
| 1072 | 5 | |
| 1073 | Subscriber Middle Na me | |
| 1074 | 25 A/N | |
| 1075 | 837: 2010B A NM105 | |
| 1076 | Print: | |
| 1077 | CMS 1500 – Box 4 | |
| 1078 | Box 13 – S ignature B lock | |
| 1079 | UB04 – FL5 8 by Payer | |
| 1080 | Biller Inp ut: N/A | |
| 1081 | Screen 3 S ection 1 | |
| 1082 | Storage: | |
| 1083 | File: PATI ENT (#2) | |
| 1084 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1085 | Field: NAM E OF INSUR ED (#17) | |
| 1086 | ||
| 1087 | 6 | |
| 1088 | Subscriber Name Suff ix | |
| 1089 | 10 A/N | |
| 1090 | 837: 2010B A NM107 | |
| 1091 | Print: | |
| 1092 | CMS 1500 – Box 4 | |
| 1093 | Box 13 – S ignature B lock | |
| 1094 | UB04 – FL5 8 by Payer | |
| 1095 | Biller Inp ut: N/A | |
| 1096 | Screen 3 S ection 1 | |
| 1097 | Storage: | |
| 1098 | File: PATI ENT (#1) | |
| 1099 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1100 | Field: NAM E OF INSUR ED (#17) | |
| 1101 | ||
| 1102 | 7 | |
| 1103 | Subscriber Birth Dat e | |
| 1104 | 8 N CCYYMM DD | |
| 1105 | 837: 2010B A DMG02 If 2000B SBR 02 = 18 | |
| 1106 | Print: | |
| 1107 | CMS 1500 – Box 11a | |
| 1108 | Biller Inp ut: N/A | |
| 1109 | Screen 3 S ection 1 | |
| 1110 | Storage: | |
| 1111 | File: PATI ENT (#2) | |
| 1112 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1113 | Field: INS URED’S DOB (#3.01) | |
| 1114 | If 2000B S BR02 <>18 then ignor e. | |
| 1115 | 8 | |
| 1116 | Subscriber Gender Co de | |
| 1117 | 1 A | |
| 1118 | 837: 2010B A DMG03 If 2000B SBR 02 = 18 | |
| 1119 | Print: | |
| 1120 | CMS 1500 – Box 11a | |
| 1121 | Biller Inp ut: N/A | |
| 1122 | Screen 3 S ection 1 | |
| 1123 | Storage: | |
| 1124 | File: PATI ENT (#2) | |
| 1125 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1126 | Field: INS URED’S SEX (#3.12) | |
| 1127 | If 2000B S BR02 <>18 then ignor e | |
| 1128 | ||
| 1129 | ||
| 1130 | CI2A - Loo p 2000B/20 10BA (Subs criber Dat a) | |
| 1131 | (REQUIRED – Max len gth 183 b ytes) | |
| 1132 | Piece | |
| 1133 | Descriptio n | |
| 1134 | Max Length | |
| 1135 | Data Type | |
| 1136 | 837/Print Location | |
| 1137 | VistA Inpu t/Storage | |
| 1138 | FSC Proces sing Comme nts | |
| 1139 | 1 | |
| 1140 | RECORD ID = ‘CI2A ’ | |
| 1141 | 4 A | |
| 1142 | ||
| 1143 | ||
| 1144 | ||
| 1145 | 2 | |
| 1146 | Payer Resp onsibility Sequence | |
| 1147 | 1 A | |
| 1148 | 837: 2000B SBR01 | |
| 1149 | Print: N/A | |
| 1150 | Biller Inp ut: Screen 3 Section 1 | |
| 1151 | Storage: | |
| 1152 | File: BILL /CLAIM (#3 99) | |
| 1153 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 1154 | Codes adde d to indic ate sequen ce out to 11 payers. VHA will only use u p to three payers by VHA. | |
| 1155 | 3 | |
| 1156 | Subscriber Address 1 | |
| 1157 | 55 A/N | |
| 1158 | 837: 2010B A N301 If 2000B SBR0 2 = 18 | |
| 1159 | Print: | |
| 1160 | CMS 1500 – Box 7 | |
| 1161 | Biller Inp ut: N/A | |
| 1162 | Screen 3 S ection 1 | |
| 1163 | Storage: | |
| 1164 | File: PATI ENT (#2) | |
| 1165 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1166 | Field: INS URED’S STR EET 1 (#3. 06) | |
| 1167 | If 2000B S BR02 <>18 then ignor e | |
| 1168 | 4 | |
| 1169 | Subscriber Address 2 | |
| 1170 | 55 A/N | |
| 1171 | 837: 2010B A N302 If 2000B SBR0 2 = 18 | |
| 1172 | Print: | |
| 1173 | CMS 1500 – Box 7 | |
| 1174 | Biller Inp ut: N/A | |
| 1175 | Screen 3 S ection 1 | |
| 1176 | Storage: | |
| 1177 | File: PATI ENT (#2) | |
| 1178 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1179 | Field: INS URED’S STR EET 2 (#3. 07) | |
| 1180 | None. If 2 000B SBR02 <>18 then ignore | |
| 1181 | 5 | |
| 1182 | Subscriber City Name | |
| 1183 | 30 A/N | |
| 1184 | 837: 2010B A N401 If 2000B SBR0 2 = 18 | |
| 1185 | Print: | |
| 1186 | CMS 1500 – Box 7 | |
| 1187 | Biller Inp ut: N/A | |
| 1188 | Screen 3 S ection 1 | |
| 1189 | Storage: | |
| 1190 | File: PATI ENT (#2) | |
| 1191 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1192 | Field: INS URED’S CIT Y (#3.08) | |
| 1193 | If 2000B S BR02 <>18 then ignor e. | |
| 1194 | 6 | |
| 1195 | Subscriber State Cod e | |
| 1196 | 2 A/N | |
| 1197 | 837: 2010B A N402 If 2000B SBR0 2 = 18 | |
| 1198 | Print: | |
| 1199 | CMS 1500 – Box 7 | |
| 1200 | Biller Inp ut: N/A | |
| 1201 | Screen 3 S ection 1 | |
| 1202 | Storage: | |
| 1203 | File: PATI ENT (#2) | |
| 1204 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1205 | Field: INS URED’S STA TE (#3.09) | |
| 1206 | If 2000B S BR02 <>18 then ignor e | |
| 1207 | Required w hen in US or territo ries. | |
| 1208 | 7 | |
| 1209 | Subscriber ZIP Code | |
| 1210 | 9 NUM | |
| 1211 | 837: 2010B A N403 If 2000B SBR0 2 = 18 | |
| 1212 | Print: | |
| 1213 | CMS 1500 – Box 7 | |
| 1214 | Biller Inp ut: N/A | |
| 1215 | Screen 3 S ection 1 | |
| 1216 | Storage: | |
| 1217 | File: PATI ENT (#2) | |
| 1218 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1219 | Field: INS URED’S ZIP (#3.1) | |
| 1220 | If 2000B S BR02 <>18 then ignor e | |
| 1221 | Required w hen in US or territo ries. | |
| 1222 | 8 | |
| 1223 | Subscriber Telephone Number | |
| 1224 | 20 A/N | |
| 1225 | 837: 2010B A PER04 If 2000B SBR 02 = 18 | |
| 1226 | Print: | |
| 1227 | CMS 1500 – Box 7 | |
| 1228 | Biller Inp ut: N/A | |
| 1229 | Screen 3 S ection 1 | |
| 1230 | Storage: | |
| 1231 | File: PATI ENT (#2) | |
| 1232 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1233 | Field: INS URED’S PHO NE (#3.11) | |
| 1234 | Set PER01 = IC PER03 = TE If 2 000B SBR02 <>18 then ignore | |
| 1235 | If PT2 pie ce 5 is no t null the n ignore. | |
| 1236 | CI3 - Loop 2000B (Su bscriber G roup/Emplo yment Data ) [SEQ 35] | |
| 1237 | (OPTIONAL – Max len gth 116 by tes) | |
| 1238 | Piece | |
| 1239 | Descriptio n | |
| 1240 | Max Length | |
| 1241 | Data Type | |
| 1242 | 837/Print Location | |
| 1243 | VistA Inpu t/Storage | |
| 1244 | FSC Proces sing Comme nts | |
| 1245 | 1 | |
| 1246 | RECORD ID = ‘CI3 ’ | |
| 1247 | 4 A | |
| 1248 | ||
| 1249 | ||
| 1250 | ||
| 1251 | 2 | |
| 1252 | Insured Gr oup or Pol icy # | |
| 1253 | 50 A/N | |
| 1254 | 837: 2000B SBR03 | |
| 1255 | Print: | |
| 1256 | CMS 1500 – Box 11 | |
| 1257 | UB04 – FL6 2 by Payer | |
| 1258 | Biller Inp ut: Screen 3 Section 1 | |
| 1259 | The policy is added to a bill on screen 3 but the payer must already e xist. | |
| 1260 | Insurance is entered for a spe cific pati ent in Pat ient Insur ance Info View/Edit. Once the insurance policy ex ists for a patient, it may be added to a bill and the system knows the policy na me and num ber. | |
| 1261 | Storage: | |
| 1262 | File - Ins urance Com pany (#36) | |
| 1263 | Subfile – GROUP INSU RANCE PLAN (#355.3) | |
| 1264 | Field – GR OUP NAME ( #.03) | |
| 1265 | ||
| 1266 | 3 | |
| 1267 | Insured Gr oup Name | |
| 1268 | 60 A/N | |
| 1269 | 837: 2000B SBR04 | |
| 1270 | Print: | |
| 1271 | CMS 1500 – Box 11c | |
| 1272 | UB04 – FL6 1 by Payer | |
| 1273 | Biller Inp ut: Screen 3 Section 1 | |
| 1274 | The policy is added to a bill on screen 3 but the payer must already e xist. | |
| 1275 | Insurance is entered for a spe cific pati ent in Pat ient Insur ance Info Add/Edit. Once the insurance policy exi sts for a patient, i t may be a dded to a bill and t he system knows the policy nam e and numb er. | |
| 1276 | Storage: | |
| 1277 | File – GRO UP INSURAN CE PLAN ( #355.3) | |
| 1278 | Field – GR OUP NUMBER (#.04) | |
| 1279 | ||
| 1280 | ||
| 1281 | ||
| 1282 | CI3A - Loo p 2000B (S ubscriber Group/Empl oyment Dat a) | |
| 1283 | (OPTIONAL – Max len gth 155 by tes) | |
| 1284 | Piece | |
| 1285 | Descriptio n | |
| 1286 | Max Length | |
| 1287 | Data Type | |
| 1288 | 837/Print Location | |
| 1289 | VistA Inpu t/Storage | |
| 1290 | FSC Proces sing Comme nts | |
| 1291 | 1 | |
| 1292 | RECORD ID = ‘CI3A ’ | |
| 1293 | 4 A | |
| 1294 | ||
| 1295 | ||
| 1296 | ||
| 1297 | 2 | |
| 1298 | INSURED EM PLOYER NAM E | |
| 1299 | ||
| 1300 | 30 A/N | |
| 1301 | 837: 2010B E NM103 | |
| 1302 | Print: | |
| 1303 | UB04 – FL6 5 by Payer | |
| 1304 | Biller Inp ut: N/A | |
| 1305 | The subscr iber’s emp loyment in formation is added v ia Patient Insurance Info Add/ EditAdd Po licy or Po licy Edit/ ViewEmploy er Info | |
| 1306 | File: PATI ENT (#2) | |
| 1307 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1308 | Field: SUB SCRIBER”S EMPLOYER N AME (#2.01 5) | |
| 1309 | Not a HIPA A data ele ment. | |
| 1310 | HCCH UB04 printing r equirement | |
| 1311 | Set NM101 = 84 | |
| 1312 | NM102 = 2 | |
| 1313 | 3 | |
| 1314 | Claim Fili ng Indicat or Code | |
| 1315 | (Type of P ayer/Sourc e of Pay) | |
| 1316 | 2 A | |
| 1317 | 837: 2000B SBR09 | |
| 1318 | Print: | |
| 1319 | CMS 1500 – Box 1 | |
| 1320 | ||
| 1321 | Note: CI w ill be use d as a def ault when there is n o value in File 355. 3. | |
| 1322 | Biller Inp ut: Screen 3 Section 1 | |
| 1323 | The policy is added to a bill on screen 3 but the payer must already e xist. | |
| 1324 | Insurance is entered for a spe cific pati ent in Pat ient Insur ance Info Add/Edit. Once the insurance policy exi sts for a patient, i t may be a dded to a bill and t he system knows the electronic type. Th e plan may be edited in Insura nce Compan y Entry/Ed itView Pla ns. | |
| 1325 | Storage: | |
| 1326 | File – GRO UP INSURAN CE PLAN ( #355.3) | |
| 1327 | Field – EL ECTRONIC P LAN TYPE ( #.15) | |
| 1328 | Code set u pdate. | |
| 1329 | 4 | |
| 1330 | Prior Auth orization # | |
| 1331 | 35 A/N | |
| 1332 | ||
| 1333 | 837: 2300 REF02 | |
| 1334 | Print: | |
| 1335 | CMS 1500 – Box 23 | |
| 1336 | UB04 – FL6 3 by payer | |
| 1337 | ||
| 1338 | Note: Syst em keeps t rack of th e payer se quence. | |
| 1339 | Biller Inp ut: Screen 10 Sectio n 1/2 | |
| 1340 | Storage: | |
| 1341 | File: BILL /CLAIM (#3 99) | |
| 1342 | Field: TRE ATMENT AUT HORIZATION CODE (#16 3) | |
| 1343 | Field: SEC ONDARY AUT HORIZATION CODE (#23 0) | |
| 1344 | Field: TER TIARY AUTH ORIZATION CODE (#231 ) | |
| 1345 | Max length is 50 | |
| 1346 | 5 | |
| 1347 | Payer Clai m Control Number Qua lifier | |
| 1348 | 2 A/N | |
| 1349 | 837: 2300 REF01 | |
| 1350 | Print: N/A | |
| 1351 | Biller Inp ut: N/A | |
| 1352 | Storage: N /A | |
| 1353 | Note: Alwa ys F8 | |
| 1354 | ||
| 1355 | 6 | |
| 1356 | Payer Clai m Control Number | |
| 1357 | 50 A/N | |
| 1358 | 837: 2300 REF02 | |
| 1359 | Print: | |
| 1360 | UB04 – FL6 4 by payer | |
| 1361 | Biller Inp ut: Screen 10 Sectio n 1/2 | |
| 1362 | This is th e ICN/DCN received i n an 835 a nd is used with repl acement cl aims. On s econdary a nd tertiar y claims, the number (s) will b e automati cally popu lated. | |
| 1363 | Storage: | |
| 1364 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 1365 | Field: ICN (#.14) | |
| 1366 | ||
| 1367 | 7 | |
| 1368 | Prior Auth orization Qualifier | |
| 1369 | 2 A/N | |
| 1370 | 837: 2300 REF01 | |
| 1371 | Print: N/A | |
| 1372 | Biller Inp ut: N/A | |
| 1373 | Storage: N /A | |
| 1374 | Note: Alwa ys G1 | |
| 1375 | ||
| 1376 | 8 | |
| 1377 | Referral N umber Qual ifier | |
| 1378 | 2 A/N | |
| 1379 | 837: 2300 REF01 | |
| 1380 | Print: N/A | |
| 1381 | Biller Inp ut: N/A | |
| 1382 | Storage: N /A | |
| 1383 | Note: Alwa ys 9F | |
| 1384 | ||
| 1385 | 9 | |
| 1386 | Referral N umber | |
| 1387 | 20 A/N | |
| 1388 | 837: 2300 REF02 | |
| 1389 | Print: N/A | |
| 1390 | Biller Inp ut: Screen 10 Sectio n 1/2 | |
| 1391 | Storage: | |
| 1392 | File: BILL /CLAIM (#3 99) | |
| 1393 | Field: PRI MARY REFER RAL CODE ( #253) | |
| 1394 | Max length is 50 | |
| 1395 | ||
| 1396 | CI5 - Loop 2010BB/BC (Payer ID Data) [SE Q 37] | |
| 1397 | (REQUIRED – Max len gth 237 by tes) | |
| 1398 | Piece | |
| 1399 | Descriptio n | |
| 1400 | Max Length | |
| 1401 | Data Type | |
| 1402 | 837/Print Location | |
| 1403 | VistA Inpu t/Storage | |
| 1404 | FSC Proces sing Comme nts | |
| 1405 | 1 | |
| 1406 | RECORD ID = ‘CI5 ’ | |
| 1407 | 4 A | |
| 1408 | N/A | |
| 1409 | ||
| 1410 | ||
| 1411 | 2 | |
| 1412 | Payer Prim ary ID Qua lifier | |
| 1413 | 3 A/N | |
| 1414 | 837: 2010B B NM108 | |
| 1415 | Print: N/A | |
| 1416 | Biller Inp ut: N/A | |
| 1417 | Storage: N /A | |
| 1418 | Note: Alwa ys PI | |
| 1419 | 837I: Loop changed t o 2010BB | |
| 1420 | ||
| 1421 | 3 | |
| 1422 | Payer Prim ary ID (Em deon Payer ID) | |
| 1423 | 20 A/N | |
| 1424 | 837: 2010B B NM109 | |
| 1425 | Print: | |
| 1426 | UB04 – FL5 1 by payer | |
| 1427 | ||
| 1428 | Note: This is the le gacy Prima ry ID. **I t will onl y print if there is no HPID.** | |
| 1429 | Biller Inp ut: N/A | |
| 1430 | Screen 3 S ection 3 | |
| 1431 | The Payer IDs are au tomaticall y entered on a bill when the u ser adds t he insuran ce to the claim. Pa yer IDs ar e enter in Insurance Company E ntry/EditB illing/EDI Param | |
| 1432 | Storage: | |
| 1433 | File: INSU RANCE COMP ANY (#36) | |
| 1434 | Field: EDI ID NUMBER – PROF (# 3.02) | |
| 1435 | Field: EDI ID NUMBER – INST (# 3.04) | |
| 1436 | 837I: Loop changed t o 2010BB. | |
| 1437 | 4 | |
| 1438 | Payer Seco ndary ID Q ualifier ( 1) | |
| 1439 | 3 A/N | |
| 1440 | 837: 2010B B REF01 | |
| 1441 | Print: N/A | |
| 1442 | Biller Inp ut: N/A | |
| 1443 | Screen 3 S ection 3 | |
| 1444 | The Payer IDs are au tomaticall y entered on a bill when the u ser adds t he insuran ce to the claim. Pa yer IDs ar e enter in Insurance Company E ntry/EditB illing/EDI Param | |
| 1445 | Storage: | |
| 1446 | File: INSU RANCE COMP ANY (#36) | |
| 1447 | Field: EDI INST SECO NDARY ID Q UAL (1) (# 6.01) | |
| 1448 | Field: EDI PROF SECO NDARY ID Q UAL (1) (# 6.05) | |
| 1449 | 837I: Loop changed t o 2010BB. | |
| 1450 | ||
| 1451 | Code Set C hange: All owed Value s - 2U, EI , FY, NF. | |
| 1452 | 5 | |
| 1453 | Payer Seco ndary ID ( 1) | |
| 1454 | 30 A/N | |
| 1455 | 837: 2010B B REF02 | |
| 1456 | Print: N/A | |
| 1457 | Biller Inp ut: N/A | |
| 1458 | Screen 3 S ection 3 | |
| 1459 | Storage: | |
| 1460 | File: INSU RANCE COMP ANY (#36) | |
| 1461 | Field: EDI INST SECO NDARY ID ( 1) (#6.02) | |
| 1462 | Field: EDI PROF SECO NDARY ID ( 1) (#6.06) | |
| 1463 | 837I: Loop changed t o 2010BB. | |
| 1464 | 6 | |
| 1465 | Payer Seco ndary ID Q ualifier ( 2) | |
| 1466 | 3 A/N | |
| 1467 | 2010BB REF 01 | |
| 1468 | Biller Inp ut: N/A | |
| 1469 | Screen 3 S ection 3 | |
| 1470 | Storage: | |
| 1471 | File: INSU RANCE COMP ANY (#36) | |
| 1472 | Field: EDI INST SECO NDARY ID Q UAL (2) (# 6.03) | |
| 1473 | Field: EDI PROF SECO NDARY ID Q UAL (2) (# 6.07) | |
| 1474 | 837I: Loop changed t o 2010BB. | |
| 1475 | Code Set C hange: All owed Value s - 2U, EI , FY, NF. | |
| 1476 | ||
| 1477 | 7 | |
| 1478 | Payer Seco ndary ID ( 2) | |
| 1479 | 30 A/N | |
| 1480 | 837: 2010B B REF02 | |
| 1481 | Print: N/A | |
| 1482 | Biller Inp ut: N/A | |
| 1483 | Screen 3 S ection 3 | |
| 1484 | Storage: | |
| 1485 | File: INSU RANCE COMP ANY (#36) | |
| 1486 | Field: EDI INST SECO NDARY ID ( 2) (#6.04) | |
| 1487 | Field: EDI PROF SECO NDARY ID ( 2) (#6.08) | |
| 1488 | 837I: Loop changed t o 2010BB. | |
| 1489 | 8 | |
| 1490 | Payer ID Q ualifier | |
| 1491 | 2 A/N | |
| 1492 | 837: 2010B B NM108 | |
| 1493 | Print: N/A | |
| 1494 | Biller Inp ut: N/A | |
| 1495 | Storage: N /A | |
| 1496 | Note: Alwa ys XV | |
| 1497 | ||
| 1498 | 9 | |
| 1499 | Payer Prim ary ID (HP ID) | |
| 1500 | 80 A/N | |
| 1501 | 837: 2010B B NM109 | |
| 1502 | Print: | |
| 1503 | UB04 – FL5 1 by payer | |
| 1504 | Biller Inp ut: N/A | |
| 1505 | Screen 3 S ection 3 | |
| 1506 | The Payer IDs are au tomaticall y entered on a bill when the u ser adds t he insuran ce to the claim. Pa yer IDs ar e entered in Insura nce Compan y Entry/Ed itBilling/ EDI Param | |
| 1507 | Storage: | |
| 1508 | File: INSU RANCE COMP ANY (#36) | |
| 1509 | Field: TBD | |
| 1510 | ||
| 1511 | ||
| 1512 | ||
| 1513 | CI6 - Loop 2010BA (S ubscriber ID Data) [ SEQ 38] | |
| 1514 | (REQUIRED – Max len gth 144 by tes) | |
| 1515 | Piece | |
| 1516 | Descriptio n | |
| 1517 | Max Length | |
| 1518 | Data Type | |
| 1519 | 837/Print Location | |
| 1520 | VistA Inpu t/Storage | |
| 1521 | FSC Proces sing Comme nts | |
| 1522 | 1 | |
| 1523 | RECORD ID = ‘CI6 ’ | |
| 1524 | 4 A | |
| 1525 | ||
| 1526 | ||
| 1527 | ||
| 1528 | 2 | |
| 1529 | Subscriber Primary I D Qualifie r | |
| 1530 | 3 A/N | |
| 1531 | 837: 2010B A NM108 | |
| 1532 | Print: N/A | |
| 1533 | ||
| 1534 | Biller Inp ut: N/A | |
| 1535 | Storage: N /A | |
| 1536 | Note: Alwa ys MI. | |
| 1537 | Usage chan ged to req uired | |
| 1538 | 3 | |
| 1539 | Subscriber Primary I D | |
| 1540 | 80 A/N | |
| 1541 | 837: 2010B A NM109 | |
| 1542 | Print: | |
| 1543 | CMS 1500 – Box 1a | |
| 1544 | UB04 – FL6 0 by payer | |
| 1545 | Biller Inp ut: N/A | |
| 1546 | Screen 3 S ection 1 | |
| 1547 | The biller can add t he patient ’s insuran ce policy to the bil l on Scree n 3 Sectio n 1. The Subscriber informati on is main tained in Patient In surance In fo View/Ed itAdd Poli cy or Poli cy View/Ed itSubscrib er Updates | |
| 1548 | Storage: | |
| 1549 | File: PATI ENT (#2) | |
| 1550 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1551 | Field: SUB SCRIBER ID (#11) | |
| 1552 | Usage chan ged to req uired | |
| 1553 | 4 | |
| 1554 | Subscriber Secondary Qualifier (1) | |
| 1555 | 3 A/N | |
| 1556 | 837: 2010B A REF01 | |
| 1557 | Print: N/A | |
| 1558 | Biller Inp ut: N/A | |
| 1559 | Screen 3 S ection 1 | |
| 1560 | The biller can add t he patient ’s insuran ce policy to the bil l on Scree n 3 Sectio n 1. The Subscriber informati on is main tained in Patient In surance In fo View/Ed itAdd Poli cy or Poli cy View/Ed itSubscrib er Updates | |
| 1561 | Storage: | |
| 1562 | File: PATI ENT (#2) | |
| 1563 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1564 | Field: SUB SCRIBER’s SEC QUALIF IER(1) ID (#5.02) | |
| 1565 | ||
| 1566 | 5 | |
| 1567 | Subscriber Secondary ID(1) | |
| 1568 | 50 A/N | |
| 1569 | 837: 2010B A REF02 | |
| 1570 | Biller Inp ut: N/A | |
| 1571 | Screen 3 S ection 1 | |
| 1572 | The biller can add t he patient ’s insuran ce policy to the bil l on Scree n 3 Sectio n 1. The Subscriber informati on is main tained in Patient In surance In fo View/Ed itAdd Poli cy or Poli cy View/Ed itSubscrib er Updates | |
| 1573 | Storage: | |
| 1574 | File: PATI ENT (#2) | |
| 1575 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1576 | Field: SUB SCRIBER’S SEC ID(1) (#5.03) | |
| 1577 | ||
| 1578 | ||
| 1579 | PT1 - Loop 2000B/C 2 010BA/CA ( Patient Da ta) [SEQ 4 0] | |
| 1580 | If the pat ient has b een issued a unique identifica tion numbe r by the p ayer then they are c onsidered the subscr iber and t he 2010CA loop is no t submitte d. | |
| 1581 | (REQUIRED – Max len gth 255 b ytes) | |
| 1582 | Piece | |
| 1583 | Descriptio n | |
| 1584 | Max Length | |
| 1585 | Data Type | |
| 1586 | 837/Print Location | |
| 1587 | VistA/Inpu t/Storage | |
| 1588 | FSC Proces sing Comme nts | |
| 1589 | 1 | |
| 1590 | RECORD ID = ‘PT1 ’ | |
| 1591 | 4 A | |
| 1592 | ||
| 1593 | ||
| 1594 | ||
| 1595 | 2 | |
| 1596 | Pt Relatio nship to I nsured | |
| 1597 | 2 A/N | |
| 1598 | 837: | |
| 1599 | 2000B SBR0 2 if equal to 18 | |
| 1600 | or | |
| 1601 | 2000C PAT0 1 if not e qual to 18 | |
| 1602 | Print: | |
| 1603 | CMS 1500 – Box 6 | |
| 1604 | UB04 – FL5 9 by payer | |
| 1605 | Biller Inp ut: N/A | |
| 1606 | Screen 3 S ection 1 | |
| 1607 | The biller can add t he patient ’s insuran ce policy to the bil l on Scree n 3 Sectio n 1. The Subscriber informati on is main tained in Patient In surance In fo View/Ed itAdd Poli cy or Poli cy View/Ed itSubscrib er Updates | |
| 1608 | Storage: | |
| 1609 | File: PATI ENT (#2) | |
| 1610 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 1611 | Field: PT. RELATIONS HIP - HIPA A (#4.03) | |
| 1612 | None | |
| 1613 | 3 | |
| 1614 | BLANK | |
| 1615 | 1 | |
| 1616 | ||
| 1617 | ||
| 1618 | ||
| 1619 | 4 | |
| 1620 | Pt Last Na me | |
| 1621 | 30 A/N | |
| 1622 | 837: 2010C A NM104 | |
| 1623 | Print: | |
| 1624 | CMS 1500 – Box 2 | |
| 1625 | Box 12 as signature | |
| 1626 | UB04 – FL8 b | |
| 1627 | Biller Inp ut: N/A | |
| 1628 | The patien t is selec ted by a u ser from t he Patient file | |
| 1629 | File: PATI ENT (#2) | |
| 1630 | Field: NAM E (#.01) | |
| 1631 | Maximum HI PAA length is 60. | |
| 1632 | Set NM101 = QC | |
| 1633 | NM102 = 1 | |
| 1634 | 5 | |
| 1635 | Pt First N ame | |
| 1636 | 20 A/N | |
| 1637 | 837: 2010C A NM104 | |
| 1638 | Print: | |
| 1639 | CMS 1500 – Box 2 | |
| 1640 | Box 12 as signature | |
| 1641 | UB04 – FL8 b | |
| 1642 | Biller Inp ut: N/A | |
| 1643 | The patien t is selec ted by a u ser from t he Patient file | |
| 1644 | File: PATI ENT (#2) | |
| 1645 | Field: NAM E (#.01) | |
| 1646 | Maximum HI PAA length is 35 | |
| 1647 | 6 | |
| 1648 | Pt Middle Name | |
| 1649 | 25 A/N | |
| 1650 | 837: 2010C A NM104 | |
| 1651 | Print: | |
| 1652 | CMS 1500 – Box 2 | |
| 1653 | Box 12 as signature | |
| 1654 | UB04 – FL8 b | |
| 1655 | Biller Inp ut: N/A | |
| 1656 | The patien t is selec ted by a u ser from t he Patient file | |
| 1657 | File: PATI ENT (#2) | |
| 1658 | Field: NAM E (#.01) | |
| 1659 | ||
| 1660 | 7 | |
| 1661 | Pt Address 1 | |
| 1662 | 35 A/N | |
| 1663 | 837: 2010C A N301 | |
| 1664 | Print: | |
| 1665 | CMS 1500 – Box 5 | |
| 1666 | UB04 – FL9 a | |
| 1667 | Biller Inp ut: N/A | |
| 1668 | The patien t is selec ted by a u ser from t he Patient file | |
| 1669 | File: PATI ENT (#2) | |
| 1670 | Field: STR EET ADDRES S [LINE 1] (#.111) | |
| 1671 | ||
| 1672 | 8 | |
| 1673 | Pt Address 2 | |
| 1674 | 35 A/N | |
| 1675 | 837: 2010C A N302 | |
| 1676 | Print: | |
| 1677 | CMS 1500 – Box 5 | |
| 1678 | Biller Inp ut: N/A | |
| 1679 | The patien t is selec ted by a u ser from t he Patient file | |
| 1680 | File: PATI ENT (#2) | |
| 1681 | Field: STR EET ADDRES S [LINE 2] (#.112) | |
| 1682 | ||
| 1683 | 9 | |
| 1684 | Pt City Na me | |
| 1685 | 30 A/N | |
| 1686 | 837: 2010C A N401 | |
| 1687 | Print: | |
| 1688 | CMS 1500 – Box 5 | |
| 1689 | UB04 – FL9 b | |
| 1690 | Biller Inp ut: N/A | |
| 1691 | The patien t is selec ted by a u ser from t he Patient file | |
| 1692 | File: PATI ENT (#2) | |
| 1693 | Field: CIT Y (#.114) | |
| 1694 | ||
| 1695 | 10 | |
| 1696 | Pt State C ode | |
| 1697 | 2 A/N | |
| 1698 | 837: 2010C A N402 | |
| 1699 | Print: | |
| 1700 | CMS 1500 – Box 5 | |
| 1701 | UB04 – FL9 c | |
| 1702 | Biller Inp ut: N/A | |
| 1703 | The patien t is selec ted by a u ser from t he Patient file | |
| 1704 | File: PATI ENT (#2) | |
| 1705 | Field: STA TE (#.115) | |
| 1706 | Required w hen in US or territo ries. | |
| 1707 | 11 | |
| 1708 | Pt ZIP Cod e | |
| 1709 | 9 NUM | |
| 1710 | 837: 2010C A N403 | |
| 1711 | Print: | |
| 1712 | CMS 1500 – Box 5 | |
| 1713 | UB04 – FL9 d | |
| 1714 | Biller Inp ut: N/A | |
| 1715 | The patien t is selec ted by a u ser from t he Patient file | |
| 1716 | File: PATI ENT (#2) | |
| 1717 | Field: ZIP CODE (#.1 16) | |
| 1718 | Required w hen in | |
| 1719 | US or terr itories. | |
| 1720 | 12 | |
| 1721 | Pt Birth D T | |
| 1722 | 8 NUM CCYY MMDD | |
| 1723 | 837: 2010C A DMG02 | |
| 1724 | Print: | |
| 1725 | CMS 1500 – Box 3 | |
| 1726 | UB04 – FL1 0 | |
| 1727 | Biller Inp ut: N/A | |
| 1728 | The patien t is selec ted by a u ser from t he Patient file | |
| 1729 | File: PATI ENT (#2) | |
| 1730 | Field: DAT E OF BIRTH (#.03) | |
| 1731 | Set DMG01 =D8 | |
| 1732 | 13 | |
| 1733 | Pt Gender Code | |
| 1734 | 1 A/N | |
| 1735 | 837: 2010C A DMG03 | |
| 1736 | Print: | |
| 1737 | CMS 1500 – Box 3 | |
| 1738 | UB04 – FL1 1 | |
| 1739 | Biller Inp ut: N/A | |
| 1740 | The patien t is selec ted by a u ser from t he Patient file | |
| 1741 | File: PATI ENT (#2) | |
| 1742 | Field: SEX (#.02) | |
| 1743 | ||
| 1744 | 14 | |
| 1745 | BLANK | |
| 1746 | 1 | |
| 1747 | ||
| 1748 | ||
| 1749 | ||
| 1750 | 15 | |
| 1751 | BLANK | |
| 1752 | 1 | |
| 1753 | ||
| 1754 | ||
| 1755 | ||
| 1756 | 16 | |
| 1757 | Medical Re cord Numbe r | |
| 1758 | 20 A/N | |
| 1759 | 837: | |
| 1760 | (I) 2300 R EF02 | |
| 1761 | Print: | |
| 1762 | CMS 1500 – N/A | |
| 1763 | UB04 – FL3 b | |
| 1764 | Biller Inp ut: N/A | |
| 1765 | This is th e patient’ s SSN. | |
| 1766 | Storage: | |
| 1767 | File: PATI ENT (#2) | |
| 1768 | Field: SSN (#.09) | |
| 1769 | Maximum si ze is 50 | |
| 1770 | Set REF01 = EA | |
| 1771 | 17 | |
| 1772 | BLANK | |
| 1773 | 1 | |
| 1774 | ||
| 1775 | ||
| 1776 | ||
| 1777 | 18 | |
| 1778 | BLANK | |
| 1779 | 1 | |
| 1780 | ||
| 1781 | ||
| 1782 | ||
| 1783 | 19 | |
| 1784 | BLANK | |
| 1785 | 1 | |
| 1786 | ||
| 1787 | ||
| 1788 | ||
| 1789 | 20 | |
| 1790 | Pt Name Su ffix | |
| 1791 | 10 A | |
| 1792 | 837: 2010C A NM104 | |
| 1793 | Print: | |
| 1794 | CMS 1500 – Box 2 | |
| 1795 | Box 12 as signature | |
| 1796 | UB04 – FL8 b | |
| 1797 | Biller Inp ut: N/A | |
| 1798 | The patien t is selec ted by a u ser from t he Patient file | |
| 1799 | File: PATI ENT (#2) | |
| 1800 | Field: NAM E (#.01) | |
| 1801 | None | |
| 1802 | PT2 - Loop 2000B/C 2 010CA (Pat ient Data) [SEQ45] | |
| 1803 | The inform ation from this segm ent will b e mapped t o the subs criber loo p if the r elationshi p is 18 ot herwise it will be m apped to t he patient loop. | |
| 1804 | (OPTIONAL – Max len gth 163 b ytes) | |
| 1805 | Piece | |
| 1806 | Descriptio n | |
| 1807 | Max Length | |
| 1808 | Data Type | |
| 1809 | 837/Print Location | |
| 1810 | VistA Inpu t/Storage | |
| 1811 | FSC Proces sing Comme nts | |
| 1812 | 1 | |
| 1813 | RECORD ID = ‘PT2 ’ | |
| 1814 | 4 A | |
| 1815 | ||
| 1816 | ||
| 1817 | ||
| 1818 | 2 | |
| 1819 | BLANK | |
| 1820 | 1 | |
| 1821 | ||
| 1822 | ||
| 1823 | ||
| 1824 | 3 | |
| 1825 | Patient Te lephone Nu mber | |
| 1826 | 20 A/N | |
| 1827 | 837: 2010C A PER04 | |
| 1828 | Print: | |
| 1829 | CMS 1500 – Box 5 | |
| 1830 | Biller Inp ut: N/A | |
| 1831 | The patien t is selec ted by a u ser from t he Patient file | |
| 1832 | Storage: | |
| 1833 | File: PATI ENT (#2) | |
| 1834 | Field: PHO NE NUMBER [RESIDENCE ] (#.131) | |
| 1835 | Set PER01 = IC | |
| 1836 | Set PER03 = TE | |
| 1837 | Only map i f the PT2 piece 5 is null. | |
| 1838 | 4 | |
| 1839 | Insured or Pt Death Date | |
| 1840 | 8 NUM CCYY MMDD | |
| 1841 | 837: | |
| 1842 | (P) 2000B PAT06 or | |
| 1843 | (P) 2000C PAT06 | |
| 1844 | Print: N/A | |
| 1845 | Biller Inp ut: N/A | |
| 1846 | The patien t is selec ted by a u ser from t he Patient file | |
| 1847 | Storage: | |
| 1848 | File: PATI ENT (#2) | |
| 1849 | Field: DAT E OF DEATH (#.351) | |
| 1850 | Map to 200 0B if SBR0 2 is 18 ot herwise ma p to 2000C | |
| 1851 | 5 | |
| 1852 | Property/C asualty Cl aim Number Qualifier | |
| 1853 | 3 A/N | |
| 1854 | 837: | |
| 1855 | 2010BA REF 01 or | |
| 1856 | 2010CA REF 01 | |
| 1857 | Print: | |
| 1858 | CMS 1500 B ox 11b | |
| 1859 | Biller Inp ut: N/A | |
| 1860 | Screen 8 S ection 2 | |
| 1861 | The qualif ier Y4 is automatica lly added by the out put format ter when a P&C numbe r is prese nt. | |
| 1862 | Map to 201 0BA if SBR 02 is 18 o therwise m ap to 2010 CA | |
| 1863 | Must by Y4 | |
| 1864 | 6 | |
| 1865 | Property/C asualty Cl aim Number | |
| 1866 | 30 A/N | |
| 1867 | 837: | |
| 1868 | 2010BA REF 02 or | |
| 1869 | 2010CA REF 02 | |
| 1870 | Print: | |
| 1871 | CMS 1500 B ox 11b | |
| 1872 | Biller Inp ut: Screen 8 Section 2 | |
| 1873 | Storage: | |
| 1874 | File: BILL /CLAIM (#3 99) | |
| 1875 | Field: PRO PERTY/CASU ALTY CLAIM NUMBER (# 261) | |
| 1876 | Map to 201 0BA if SBR 02 is 18 o therwise m ap to 2010 CA | |
| 1877 | Max length 50. | |
| 1878 | 7 | |
| 1879 | Property a nd Casualt y Contact Qualifier | |
| 1880 | 2 A | |
| 1881 | 837: | |
| 1882 | (P)2010BA PER01 or ( P)2010CA P ER01 | |
| 1883 | Print: N/A | |
| 1884 | Biller Inp ut: N/A | |
| 1885 | Storage: N /A | |
| 1886 | Note: Alwa ys IC | |
| 1887 | Map to 201 0BA if SBR 02 is 18 o therwise m ap to 2010 CA | |
| 1888 | ||
| 1889 | 8 | |
| 1890 | Property a nd Casualt y Contact Name | |
| 1891 | 60 A | |
| 1892 | 837: | |
| 1893 | (P)2010BA PER02 or ( P)2010CA P ER02 | |
| 1894 | Print: N/A | |
| 1895 | Biller Inp ut: Screen 8 Section 2 | |
| 1896 | Storage: | |
| 1897 | File: BILL /CLAIM (#3 99) | |
| 1898 | Field: PRO PERTY/CASU ALTY CONTA CT NAME (# 268) | |
| 1899 | Map to 201 0BA if SBR 02 is 18 o therwise m ap to 2010 CA | |
| 1900 | None | |
| 1901 | 9 | |
| 1902 | Property a nd Casualt y Telephon e Qualifie r | |
| 1903 | 2 A | |
| 1904 | 837: | |
| 1905 | (P)2010BA PER03 or | |
| 1906 | (P)2010CA PER03 | |
| 1907 | Print: N/A | |
| 1908 | Biller Inp ut: N/A | |
| 1909 | Storage: N /A | |
| 1910 | Note: Alwa ys TE | |
| 1911 | Map to 201 0BA if SBR 02 is 18 o therwise m ap to 2010 CA | |
| 1912 | ||
| 1913 | 10 | |
| 1914 | Property a nd Casualt y Telephon e Number | |
| 1915 | 10 N | |
| 1916 | 837: | |
| 1917 | (P)2010BA PER04 or | |
| 1918 | (P)2010CA PER04 | |
| 1919 | Print: N/A | |
| 1920 | Biller Inp ut: Screen 8 Section 2 | |
| 1921 | Storage: | |
| 1922 | File: BILL /CLAIM (#3 99) | |
| 1923 | Field: PRO PERTY/CASU ALTY CLAIM NUMBER (# 261) | |
| 1924 | Map to 201 0BA if SBR 02 is 18 o therwise m ap to 2010 CA | |
| 1925 | 11 | |
| 1926 | Property a nd Casualt y Extensio n Qualifie r | |
| 1927 | 2 A | |
| 1928 | 837: | |
| 1929 | (P)2010BA PER05 or | |
| 1930 | (P)2010CA PER05 | |
| 1931 | Print: N/A | |
| 1932 | Biller Inp ut: N/A | |
| 1933 | Storage: N /A | |
| 1934 | Note: Alwa ys EX | |
| 1935 | Map to 201 0BA if SBR 09 is 18 o therwise m ap to 2010 CA | |
| 1936 | ||
| 1937 | 12 | |
| 1938 | Property a nd Casualt y Extensio n Number | |
| 1939 | 10 N | |
| 1940 | 837: | |
| 1941 | (P)2010BA PER06 or | |
| 1942 | (P)2010CA PER06 | |
| 1943 | Print: N/A | |
| 1944 | Biller Inp ut: Screen 8 Section 2 | |
| 1945 | Storage: | |
| 1946 | File: BILL /CLAIM (#3 99) | |
| 1947 | Field: PRO P/CAS EXTE NSION NUMB ER (#269) | |
| 1948 | Map to 201 0BA if SBR 02 is 18 o therwise m ap to 2010 CA | |
| 1949 | None | |
| 1950 | Section 3 – Claim Le vel Data | |
| 1951 | Claim Leve l data occ urs once p er insuran ce company /claim com bination. Record ID = CL1 mus t be prese nt for any of the ot her record types to be valid. | |
| 1952 | CL1 - Loop 2300 (Cla im Level D ata) [SEQ 50] | |
| 1953 | (REQUIRED – Max len gth 236 by tes) | |
| 1954 | Piece | |
| 1955 | Descriptio n | |
| 1956 | Max Length | |
| 1957 | Data Type | |
| 1958 | 837/Print Location | |
| 1959 | VistA Inpu t/Storage | |
| 1960 | FSC Proces sing Comme nts | |
| 1961 | 1 | |
| 1962 | RECORD ID = ‘CL1 ’ | |
| 1963 | 4 A | |
| 1964 | ||
| 1965 | ||
| 1966 | ||
| 1967 | 2 | |
| 1968 | Pt Control # | |
| 1969 | (Claim Num ber) | |
| 1970 | 38 A/N | |
| 1971 | 837: 2300 CLM01 | |
| 1972 | Print: | |
| 1973 | CMS 1500 – Box 26 | |
| 1974 | UB04 – FL3 a | |
| 1975 | Biller Inp ut: N/A | |
| 1976 | The claim number is system gen erated whe n a claim is created . | |
| 1977 | Storage: | |
| 1978 | File: BILL /CLAIM (#3 99) | |
| 1979 | Field: BIL L NUMBER ( #.01) | |
| 1980 | ||
| 1981 | 3 | |
| 1982 | Facility T ype Code | |
| 1983 | (Location of Care - Type of Bi ll) | |
| 1984 | 1 A/N | |
| 1985 | ||
| 1986 | ||
| 1987 | 837: (I) 2 300 CLM05 - 1 | |
| 1988 | Print: | |
| 1989 | UB04 – FL4 | |
| 1990 | Biller Inp ut: Screen 6 Sectio n 1 | |
| 1991 | The Type o f Bill is made up of 3 parts: Location o f Care, Bi ll Classif ication an d Timefram e of Bill. Users ma y change t his inform ation in S ection 1. | |
| 1992 | Screen 7 S ection 1 | |
| 1993 | Only the T imeframe o f Bill may be change d in Secti on 1. | |
| 1994 | Storage: | |
| 1995 | File: BILL /CLAIM (#3 99) | |
| 1996 | Field: UB- 04 LOCATIO N OF CARE (#.24) | |
| 1997 | 837I piece 3 and 4 a re combine d to form the CLM05- 1 | |
| 1998 | Set CLM05- 2 to A | |
| 1999 | 4 | |
| 2000 | Type of Bi ll Classif ication | |
| 2001 | (Bill Clas sification - Type of Bill) | |
| 2002 | 1 A/N | |
| 2003 | ||
| 2004 | 837: (I) 2 300 CLM05 - 1 | |
| 2005 | Print: | |
| 2006 | UB04 – FL4 | |
| 2007 | Biller Inp ut: Screen 6 Sectio n 1 | |
| 2008 | The Type o f Bill is made up of 3 parts: Location o f Care, Bi ll Classif ication an d Timefram e of Bill. Users ma y change t his inform ation in S ection 1. | |
| 2009 | Screen 7 S ection 1 | |
| 2010 | Only the T imeframe o f Bill may be change d in Secti on 1. | |
| 2011 | Storage: | |
| 2012 | File: BILL /CLAIM (#3 99) | |
| 2013 | Field: UB- 04 BILL CL ASSIFICATI ON (#.25) | |
| 2014 | See above | |
| 2015 | 5 | |
| 2016 | Claim Freq uency Code | |
| 2017 | (Timeframe of Bill - Type of B ill) | |
| 2018 | 1 A/N | |
| 2019 | 837: 2300 CLM05 - 3 | |
| 2020 | Print: | |
| 2021 | UB04 – FL 4 | |
| 2022 | Biller Inp ut: Screen 6 Sectio n 1 | |
| 2023 | The Type o f Bill is made up of 3 parts: Location o f Care, Bi ll Classif ication an d Timefram e of Bill. Users ma y change t his inform ation in S ection 1. | |
| 2024 | Screen 7 S ection 1 | |
| 2025 | Only the T imeframe o f Bill may be change d in Secti on 1. | |
| 2026 | Storage: | |
| 2027 | File: BILL /CLAIM (#3 99) | |
| 2028 | Field: UB- 04 TIMEFRA ME OF BILL (#.26) | |
| 2029 | Sent on 83 7P and 837 I for 5010 | |
| 2030 | ||
| 2031 | 6 | |
| 2032 | CLAIM TYPE | |
| 2033 | ||
| 2034 | ||
| 2035 | 2 A | |
| 2036 | 837: N/A | |
| 2037 | Print: N/A | |
| 2038 | Note: RX f or CMS -15 00 RX clai ms and MD for CMS – 1500 500 n on-RX clai ms | |
| 2039 | Biller Inp ut: N/A | |
| 2040 | Storage: N /A | |
| 2041 | ||
| 2042 | 7 | |
| 2043 | Release of Informati on Code | |
| 2044 | ||
| 2045 | 1 A | |
| 2046 | ||
| 2047 | 837: | |
| 2048 | 2300 CLM09 | |
| 2049 | 2320 OI06 | |
| 2050 | Print: | |
| 2051 | CMS 1500 – Box 12 | |
| 2052 | UB04 – FL 52 | |
| 2053 | Biller Inp ut: Screen 6/7 Secti on 2 | |
| 2054 | A biller c an designa te a claim as sensit ive on Scr een 6/7 an d indicate that an R OI has bee n complete d. Regard less, the 837 value will alway s = Y for Yes | |
| 2055 | Storage: | |
| 2056 | File: BILL /CLAIM (#3 99) | |
| 2057 | Field: R.O .I. FORM(S ) COMPLETE D (#157) | |
| 2058 | Add to 232 0 for 837P | |
| 2059 | 8 | |
| 2060 | Assignment of Benefi ts Indicat or | |
| 2061 | 1 A | |
| 2062 | 837: | |
| 2063 | 2300 CLM08 | |
| 2064 | 2320 OI03 | |
| 2065 | Print: | |
| 2066 | CMS 1500 – Box 27 | |
| 2067 | UB04 – FL5 3 by payer | |
| 2068 | Biller Inp ut: Screen 6/7 Secti on 2 | |
| 2069 | A biller c an answer YES or NO to the Ass ignment of Benefits prompt in Section 2 if the Ass ignment of Benefits is not set when the Pt’s polic y is creat ed. | |
| 2070 | Storage: | |
| 2071 | File: GROU P INSURANC E PLAN (#3 55.3) | |
| 2072 | Field: BEN EFITS ASSI GNABLE? (# .08) | |
| 2073 | File: BILL /CLAIM (#3 99) | |
| 2074 | Field: ASS IGNMENT OF BENEFITS (#156) | |
| 2075 | Either Y o r N | |
| 2076 | 9 | |
| 2077 | Bill Statu s | |
| 2078 | 2 A/N | |
| 2079 | 837: N/A | |
| 2080 | Print: N/A | |
| 2081 | Biller Inp ut: N/A | |
| 2082 | If CLAIM M RA STATUS (File #399 , Field 24 ) = 0, the n 00 is se nt. | |
| 2083 | If the DAT E FIRST PR INTED (Fil e 399, Fie ld 12) is populated, then 00 i s sent. | |
| 2084 | If neither of the ab ove, then 15 is sent | |
| 2085 | N/A | |
| 2086 | 10 | |
| 2087 | Statement From DT | |
| 2088 | ||
| 2089 | 8 N CCYYMM DD | |
| 2090 | 837: | |
| 2091 | (P) 2300 D TP03 | |
| 2092 | (I) 2300 D TP03 (2) | |
| 2093 | Print: | |
| 2094 | CMS 1500 – Box 18 | |
| 2095 | UB04 – FL6 | |
| 2096 | Biller Inp ut: Screen 6/7 Secti on 3 | |
| 2097 | The statem ent to and from date s are init ially crea ted when t he bill is being cre ated, prio r to Scree n 1. User s may edit the dates on Screen s 6/7 Sect ion 3. | |
| 2098 | Storage: | |
| 2099 | File: BILL /CLAIM (#3 99) | |
| 2100 | Field: STA TEMENT COV ERS FROM ( #151) | |
| 2101 | 837P set D TP01 = 141 DTP 02 = D8 Non-HIP AA field H CCH print requiremen t | |
| 2102 | Piece 10 a nd 11 shou ld be comb ined into one DTP wi th DTP01 = 434 and D TP02 = RD8 | |
| 2103 | 11 | |
| 2104 | Statement To DT | |
| 2105 | 8 N CCYYMM DD | |
| 2106 | 837: (I) 2 300 DTP03 (2) | |
| 2107 | Print: | |
| 2108 | CMS 1500 – Box 18 | |
| 2109 | UB04 – FL6 | |
| 2110 | Biller Inp ut: Screen 6/7 Secti on 3 | |
| 2111 | The statem ent to and from date s are init ially crea ted when t he bill is being cre ated, prio r to Scree n 1. User s may edit the dates on Screen s 6/7 Sect ion 3. | |
| 2112 | Storage: | |
| 2113 | File: BILL /CLAIM (#3 99) | |
| 2114 | Field: STA TEMENT COV ERS TO (#1 52) | |
| 2115 | See note a bove | |
| 2116 | 12 | |
| 2117 | Estimated Claim Due Amt | |
| 2118 | 18 N | |
| 2119 | 2 Decimals | |
| 2120 | 837: | |
| 2121 | (I) 2300 A MT02 | |
| 2122 | (P) 2300 A MT02 | |
| 2123 | Print: | |
| 2124 | UB04 – FL5 5 | |
| 2125 | Biller Inp ut: N/A (C alculated) | |
| 2126 | TOTAL CHAR GES (File 399, Field 201) minu s OFFSET A MOUNT (Fil e 399, Fie ld 202) = Estimated Amount Due | |
| 2127 | Storage: N /A | |
| 2128 | Non-HIPAA field | |
| 2129 | HCCH UB04 print requ irements | |
| 2130 | Set AMT01 = C5 | |
| 2131 | 13 | |
| 2132 | Total Clai m Charge A mt | |
| 2133 | 18 N | |
| 2134 | 2 Decimals | |
| 2135 | 837: 2300 CLM02 | |
| 2136 | Print: | |
| 2137 | CMS 1500 – Box 28 | |
| 2138 | UB04 – FL4 7 Line 23 TOTALS | |
| 2139 | Biller Inp ut: N/A (C alculated) | |
| 2140 | Screen 6/7 Section 5 | |
| 2141 | Storage: | |
| 2142 | File: BILL /CLAIMS (# 399) | |
| 2143 | Field: TOT AL CHARGES (#201) | |
| 2144 | ||
| 2145 | 14 | |
| 2146 | Admission/ Start or C are DT | |
| 2147 | 8 N CCYYMM DD | |
| 2148 | 837: | |
| 2149 | (I) 2300 D TP03 (3) | |
| 2150 | (P) 2300 D TP03 (12) | |
| 2151 | Print: | |
| 2152 | CMS 1500 – Box 18 | |
| 2153 | UB04 – FL1 2 | |
| 2154 | Biller Inp ut: N/A | |
| 2155 | Screen 4 S ection 1 | |
| 2156 | Users can view the A dmission D ate/Time o n Screen 4 but they cannot cha nge it. | |
| 2157 | Inpatient: Admission Date (els e EVENT DA TE) | |
| 2158 | Storage: | |
| 2159 | File: PTF (#45) | |
| 2160 | Field: ADM ISSION DAT E (#2) els e | |
| 2161 | Non-PTF Ad mission: A dmission D ate | |
| 2162 | Storage: | |
| 2163 | File: BILL /CLAIM (#3 99) | |
| 2164 | Field: NON -PTF ADMIS SION DATE (#159.5) | |
| 2165 | Outpatient : Statemen t Covers F rom Date | |
| 2166 | Storage: | |
| 2167 | File: BILL /CLAIMS (# 399) | |
| 2168 | Field: STA TEMENT COV ERS FROM ( #151) | |
| 2169 | Set DTP01 = 435 | |
| 2170 | DTP02 = D8 | |
| 2171 | 15 | |
| 2172 | Admission Time | |
| 2173 | 4 N (HHMM) | |
| 2174 | 837: (I) 2 300 DTP03 | |
| 2175 | Print: | |
| 2176 | UB04 – FL1 3 | |
| 2177 | Biller Inp ut: N/A | |
| 2178 | Screen 4 S ection 1 | |
| 2179 | Users can view the A dmission D ate/Time o n Screen 4 but they cannot cha nge it | |
| 2180 | This infor mation is extracted by the cod e from the informati on retriev ed for Pie ce 14. | |
| 2181 | For Bill T ypes equal to 11X an d 18X, 00 is transmi tted. | |
| 2182 | If sent th en combine data elem ent with p iece 14 an d set DTP0 2 = DT. Fi nal format of combin ed data el ement is C CYYMMDDHHM M | |
| 2183 | 16 | |
| 2184 | Discharge DT | |
| 2185 | 8 N CCYYMM DD | |
| 2186 | 837: (P) 2 300 DTP03 (13) | |
| 2187 | Print: | |
| 2188 | CMS 1500 – Box 18 | |
| 2189 | Biller Inp ut: N/A | |
| 2190 | Screen 4 S ection 1 | |
| 2191 | Users can view the D ischarge D ate/Time o n Screen 4 but they cannot cha nge it | |
| 2192 | Inpatient: Discharge Date | |
| 2193 | Storage: | |
| 2194 | File: PTF (#45) | |
| 2195 | Field: DIS CHARGE DAT E (#70) el se | |
| 2196 | Non-PTF Ad mission: N on-VA Disc harge Date | |
| 2197 | Storage: | |
| 2198 | File: BILL /CLAIM (#3 99) | |
| 2199 | Field: NON -VA DISCHA RGE DATE ( #.16) | |
| 2200 | Outpatient : DISCHARG E/CHECK-OU T MOVEMENT | |
| 2201 | Storage: | |
| 2202 | File: PATI ENT MOVEME NT (#405) | |
| 2203 | Field: DIS CHARGE/CHE CK-OUT MOV EMENT (#17 ) else | |
| 2204 | State Cove rs To Date | |
| 2205 | Storage: | |
| 2206 | File: BILL /CLAIM (#3 99) | |
| 2207 | Field: STA TEMENT COV ERS TO (#1 52) | |
| 2208 | Set DTP01= 096 | |
| 2209 | DTP02 = D8 | |
| 2210 | 17 | |
| 2211 | Discharge Time | |
| 2212 | 4 N (HHMM) | |
| 2213 | 837: (I) 2 300 DTP03 (1) | |
| 2214 | Print: | |
| 2215 | UB04 – FL 16 | |
| 2216 | Biller Inp ut: N/A | |
| 2217 | Screen 4 S ection 2 | |
| 2218 | Users can view the D ischarge D ate/Time o n Screen 4 but they cannot cha nge it | |
| 2219 | This infor mation is extracted by the cod e from the informati on retriev ed for Pie ce 16. De fault valu e is 0000. | |
| 2220 | Set DTP01= 096 | |
| 2221 | DTP02 = TM . | |
| 2222 | 18 | |
| 2223 | Onset of C urrent Ill ness/Sympt om DT | |
| 2224 | 8 N CCYYMM DD | |
| 2225 | 837: (P) 2 300 DTP03 (1) | |
| 2226 | Print: | |
| 2227 | CMS 1500 – Box 14 | |
| 2228 | Biller Inp ut: Occurr ence Code | |
| 2229 | Screen 4 S ection 6 | |
| 2230 | Screen 5 S ection 7 | |
| 2231 | If the ONS ET OF SYMP TOMS/ILLNE SS oc currence c ode (11) a nd date ar e on claim , that dat e is used. | |
| 2232 | If the LA ST MENSTRU AL PERIOD occura nce code ( 10) and da te are on the claim, that date is used. | |
| 2233 | If no occu rrence cod e on the c laim, then the date will not b e populate d. | |
| 2234 | Storage: | |
| 2235 | File: BILL /CLAIMS (# 399) | |
| 2236 | Field: EVE NT DATE (# .03) | |
| 2237 | Set DTP01= 431 | |
| 2238 | DTP02 = D8 . | |
| 2239 | 19 | |
| 2240 | BLANK | |
| 2241 | 1 | |
| 2242 | ||
| 2243 | ||
| 2244 | ||
| 2245 | 20 | |
| 2246 | Last Worke d DT | |
| 2247 | 8 N CCYYMM DD | |
| 2248 | 837: | |
| 2249 | (P) 2300 D TP03 (10) | |
| 2250 | Print: | |
| 2251 | CMS 1500 – Box 16 | |
| 2252 | Biller Inp ut: Screen 10 Sectio n 1 (CMS 1 500 Only) | |
| 2253 | Storage: | |
| 2254 | File: BILL /CLAIM (#3 99) | |
| 2255 | Field: UNA BLE TO WOR K FROM (#1 66) | |
| 2256 | Set DTP01 = 297 | |
| 2257 | DTP02 = D8 | |
| 2258 | 21 | |
| 2259 | Work Retur n DT | |
| 2260 | 8 N CCYYMM DD | |
| 2261 | 837: | |
| 2262 | (P) 2300 D TP03 (11) | |
| 2263 | Print: | |
| 2264 | CMS 1500 – Box 16 | |
| 2265 | Biller Inp ut: Screen 10 Sectio n 1 (CMS 1 500 Only) | |
| 2266 | Storage: | |
| 2267 | File: BILL /CLAIM (#3 99) | |
| 2268 | Field: UNA BLE TO WOR K TO (#167 ) | |
| 2269 | DTP01 = 29 6 | |
| 2270 | DTP02 = D8 | |
| 2271 | 22 | |
| 2272 | Point of o rigin for ADM or vis it | |
| 2273 | 1 A/N | |
| 2274 | 837: (I) 2 300 CL102 | |
| 2275 | Print: | |
| 2276 | UB04 – FL1 5 | |
| 2277 | Biller Inp ut: | |
| 2278 | Screen 4 S ection 1 ( Inpatient UB04) | |
| 2279 | Screen 10 Section 1 (UB04) | |
| 2280 | File: BILL /CLAIM (#3 99) | |
| 2281 | Field: SOU RCE OF ADM ISSION (#1 59) | |
| 2282 | ||
| 2283 | 23 | |
| 2284 | Priority t ype of ADM or visit | |
| 2285 | 1 A/N | |
| 2286 | 837: (I) 2 300 CL101 | |
| 2287 | Print: | |
| 2288 | UB04 – FL1 4 | |
| 2289 | Biller Inp ut: | |
| 2290 | Screen 4 S ection 1 ( Inpatient UB04) | |
| 2291 | Screen 5 S ection 3 | |
| 2292 | File: BILL /CLAIM (#3 99) | |
| 2293 | Field: TYP E OF ADMIS SION (#158 ) | |
| 2294 | ||
| 2295 | 24 | |
| 2296 | Patient St atus Code | |
| 2297 | 2 A/N | |
| 2298 | 837: (I) 2 300 CL103 | |
| 2299 | Print: | |
| 2300 | UB04 – FL1 7 | |
| 2301 | Biller Inp ut: Screen 7 Section 1 | |
| 2302 | File: BILL /CLAIM (#3 99) | |
| 2303 | Field: DIS CHARGE STA TUS (#162) which poi nts to: | |
| 2304 | File: MCCR UTILITY ( #399.1) | |
| 2305 | Field: DIS CHARGE STA TUS (#.13) | |
| 2306 | Required s egment for Instituti onal claim s. Change to code va lue listin g. | |
| 2307 | 25 | |
| 2308 | Last Menst rual Perio d DT | |
| 2309 | ||
| 2310 | 8 N CCYYMM DD | |
| 2311 | 837: (P) 2 300 DTP03( 6) | |
| 2312 | Print: | |
| 2313 | CMS 1500 – Box 14 | |
| 2314 | Biller Inp ut: Occurr ence Code | |
| 2315 | Screen 4 S ection 6 | |
| 2316 | Screen 5 S ection 7 | |
| 2317 | If the ONS ET OF SYMP TOMS/ILLNE SS oc currence c ode (11) a nd date ar e on claim , that dat e is used. | |
| 2318 | If the LA ST MENSTRU AL PERIOD occura nce code ( 10) and da te are on the claim, that date is used. | |
| 2319 | If no occu rrence cod e on the c laim, then the date will not b e populate d. | |
| 2320 | Storage: | |
| 2321 | File: BILL /CLAIM (#3 99) | |
| 2322 | Subfile: O CCURRENCE CODE (#41) | |
| 2323 | Field: DAT E (#.02) | |
| 2324 | DTP01 = 48 4 | |
| 2325 | DTP02 = D8 | |
| 2326 | 26 | |
| 2327 | BLANK | |
| 2328 | 1 | |
| 2329 | ||
| 2330 | ||
| 2331 | ||
| 2332 | 27 | |
| 2333 | BLANK | |
| 2334 | 1 | |
| 2335 | ||
| 2336 | ||
| 2337 | ||
| 2338 | 28 | |
| 2339 | Accident/E mployment/ Related Ca uses | |
| 2340 | (Qualified by AA) | |
| 2341 | 2 A | |
| 2342 | ||
| 2343 | ||
| 2344 | 837: (P) 2 300 CLM11 - 1 | |
| 2345 | Print: | |
| 2346 | CMS 1500 – Box 10b | |
| 2347 | UB04 – FL3 1 - 34 | |
| 2348 | Note: The qualifier is determi ned from t he Occurre nce Code | |
| 2349 | Biller Inp ut: | |
| 2350 | Screen 4 S ection 6 | |
| 2351 | Screen 5 S ection 7 | |
| 2352 | Storage: | |
| 2353 | File: BILL /CLAIM (#3 99) | |
| 2354 | Subfile: O CCURRENCE CODE (#41) | |
| 2355 | Field: DAT E (#.02) | |
| 2356 | None | |
| 2357 | 29 | |
| 2358 | Accident/E mployment/ Related Ca uses | |
| 2359 | (Qualified by EM) | |
| 2360 | 2 A | |
| 2361 | 837: (P) 2 300/CLM/11 - 1 | |
| 2362 | Print: | |
| 2363 | CMS 1500 – Box 10a | |
| 2364 | UB04 – FL3 1 – 34 | |
| 2365 | Note: The qualifier is determi ned from t he Occurre nce Code | |
| 2366 | Biller Inp ut: | |
| 2367 | Screen 4 S ection 6 | |
| 2368 | Screen 5 S ection 7 | |
| 2369 | Storage: | |
| 2370 | File: BILL /CLAIM (#3 99) | |
| 2371 | Subfile: O CCURRENCE CODE (#41) | |
| 2372 | Field: DAT E (#.02) | |
| 2373 | Map to the CLM11-2 i f piece 28 is not nu ll. | |
| 2374 | 30 | |
| 2375 | Accident/E mployment/ Related Ca uses | |
| 2376 | (Qualified by OA) | |
| 2377 | 2 A | |
| 2378 | 837: (P) 2 300 CLM11 - 1 | |
| 2379 | Print: | |
| 2380 | CMS 1500 – Box 10c | |
| 2381 | UB04 – FL3 1 – 34 | |
| 2382 | Note: The qualifier is determi ned from t he Occurre nce Code | |
| 2383 | Biller Inp ut: | |
| 2384 | Screen 4 S ection 6 | |
| 2385 | Screen 5 S ection 7 | |
| 2386 | Storage: | |
| 2387 | File: BILL /CLAIM (#3 99) | |
| 2388 | Subfile: O CCURRENCE CODE (#41) | |
| 2389 | Field: DAT E (#.02) | |
| 2390 | Map to the CLM11-2 i f piece 28 or 29 is not null. Map to CLM 11-3 if pi ece 28 and 29 are no t null. | |
| 2391 | 31 | |
| 2392 | Auto Accid ent State Code | |
| 2393 | 2 A/N | |
| 2394 | 837: | |
| 2395 | (P) 2300 C LM11 - 4 | |
| 2396 | (I) 2300 R EF | |
| 2397 | Print: | |
| 2398 | CMS 1500 – Box 10b | |
| 2399 | UB04 – FL2 9 | |
| 2400 | Biller Inp ut: | |
| 2401 | Screen 4 S ection 6 | |
| 2402 | Screen 5 S ection 7 | |
| 2403 | Storage: | |
| 2404 | File: BILL /CLAIM (#3 99) | |
| 2405 | Subfile: O CCURRENCE CODE (#41) | |
| 2406 | Field: STA TE (#.03) | |
| 2407 | (I)REF01 = LU | |
| 2408 | 32 | |
| 2409 | Provider S ignature o n File | |
| 2410 | 1 A | |
| 2411 | 837: 2300 CLM06 | |
| 2412 | Print: | |
| 2413 | CMS 1500 – Box 31 as signature | |
| 2414 | Biller Inp ut: N/A | |
| 2415 | Storage: N /A | |
| 2416 | ||
| 2417 | 33 | |
| 2418 | Place of S ervice Cod e (Claim L evel) | |
| 2419 | 10 A/N | |
| 2420 | 837: (P) 2 300 CLM05- 01 | |
| 2421 | Print: N/A | |
| 2422 | Biller Inp ut: Screen 4/5 Secti on 4 | |
| 2423 | Storage: | |
| 2424 | File: BILL /CLAIM (#3 99) | |
| 2425 | Subfile: P ROCEDURES (#340) | |
| 2426 | Field: PLA CE OF SERV ICE (#9) | |
| 2427 | Set CLM05- 02 equal t o B | |
| 2428 | 34 | |
| 2429 | BLANK | |
| 2430 | 1 | |
| 2431 | ||
| 2432 | ||
| 2433 | ||
| 2434 | 35 | |
| 2435 | BLANK | |
| 2436 | 1 | |
| 2437 | ||
| 2438 | ||
| 2439 | ||
| 2440 | 36 | |
| 2441 | BLANK | |
| 2442 | 1 | |
| 2443 | ||
| 2444 | ||
| 2445 | ||
| 2446 | 37 | |
| 2447 | BLANK | |
| 2448 | 1 | |
| 2449 | ||
| 2450 | ||
| 2451 | ||
| 2452 | 38 | |
| 2453 | Accident D T | |
| 2454 | 8 N CCYYMM DD | |
| 2455 | 837: (P) 2 300 DTP03 (5) | |
| 2456 | Print: | |
| 2457 | CMS 1500 – Box 15 | |
| 2458 | Biller Inp ut: | |
| 2459 | Screen 4 S ection 6 | |
| 2460 | Screen 5 S ection 7 | |
| 2461 | Storage: | |
| 2462 | File: BILL /CLAIM (#3 99) | |
| 2463 | Subfile: O CCURRENCE CODE (#41) | |
| 2464 | Field: DAT E (#.02) | |
| 2465 | Set DTP01 = 439 | |
| 2466 | STP02 =D8 | |
| 2467 | ||
| 2468 | CL1A - Loo p 2300 (Cl aim Level Data) [SEQ 51] | |
| 2469 | (REQUIRED – Max len gth 218 by tes) | |
| 2470 | Piece | |
| 2471 | Descriptio n | |
| 2472 | Max Length | |
| 2473 | Data Type | |
| 2474 | 837/Print Location | |
| 2475 | VistA Inpu t/Storage | |
| 2476 | FSC Proces sing Comme nts | |
| 2477 | 1 | |
| 2478 | RECORD ID = ‘CL1A ’ | |
| 2479 | 4 A | |
| 2480 | ||
| 2481 | ||
| 2482 | ||
| 2483 | 2 | |
| 2484 | Initial Tr eatment DT (Spinal) | |
| 2485 | 8 N CCYYMM DD | |
| 2486 | 837: (P) 2 300 DTP03 (2) | |
| 2487 | Print: | |
| 2488 | CMS 1500 – Box 15 | |
| 2489 | Biller Inp ut: Screen 10 Sectio n 5 | |
| 2490 | Storage: | |
| 2491 | File: BILL /CLAIMS (# 399) | |
| 2492 | Field: DAT E OF INITI AL TREATME NT (#246) | |
| 2493 | Set DTP02 = D8. | |
| 2494 | DTP01 mapp ed from pi ece 10 | |
| 2495 | 3 | |
| 2496 | Last X-Ray DT (Spina l) | |
| 2497 | 8 N CCYYMM DD | |
| 2498 | 837: (P) 2 300 DTP03 (7) | |
| 2499 | Print: | |
| 2500 | CMS 1500 – Box 15 | |
| 2501 | Biller Inp ut: Screen 10 Sectio n 5 | |
| 2502 | Storage: | |
| 2503 | File: BILL /CLAIMS (# 399) | |
| 2504 | Field: LAS T XRAY DAT E (#245) | |
| 2505 | Set DTP02 = D8 | |
| 2506 | DTP01 mapp ed from pi ece 11 | |
| 2507 | 4 | |
| 2508 | BLANK | |
| 2509 | 1 | |
| 2510 | ||
| 2511 | ||
| 2512 | ||
| 2513 | 5 | |
| 2514 | Assignment code | |
| 2515 | 1 A | |
| 2516 | 837: 2300 CLM/07 | |
| 2517 | Print: N/A | |
| 2518 | Biller Inp ut: N/A | |
| 2519 | Storage: N /A | |
| 2520 | Note: Alwa ys A | |
| 2521 | Code list change | |
| 2522 | Applies to all payer s not just Medicare | |
| 2523 | 6 | |
| 2524 | Mammograph y Certific ation # | |
| 2525 | 30 A/N | |
| 2526 | 837: (P) 2 300 REF02 (6) | |
| 2527 | Print: N/A | |
| 2528 | ||
| 2529 | Biller Inp ut: Screen 10 Sectio n 4 | |
| 2530 | Storage: | |
| 2531 | File: BILL /CLAIMS (# 399) | |
| 2532 | Field: MAM MOGRAPHY C ERT NUMBER (#242) | |
| 2533 | Maximum HI PAA length is 50. | |
| 2534 | REF mapped from piec e 9 | |
| 2535 | 7 | |
| 2536 | Patient Co ndition De scription (Spinal) | |
| 2537 | 1 A | |
| 2538 | 837: (P) 2 300 CR208 | |
| 2539 | Print: N/A | |
| 2540 | Biller Inp ut: Screen 10 Sectio n 5 | |
| 2541 | Storage: | |
| 2542 | File: BILL /CLAIMS (# 399) | |
| 2543 | Field: PAT IENT CONDI TION CODE (#248) | |
| 2544 | ||
| 2545 | 8 | |
| 2546 | Acute Mani festation DT (Spinal ) | |
| 2547 | 8 N CCYYMM DD | |
| 2548 | 837: (P) 2 300 DTP03 (4) | |
| 2549 | Print: N/A | |
| 2550 | Biller Inp ut: Screen 10 Sectio n 5 | |
| 2551 | Storage: | |
| 2552 | File: BILL /CLAIMS (# 399) | |
| 2553 | Field: DAT E OF ACUTE MANIFESTA TION (#247 ) | |
| 2554 | DTP01 = 45 3 | |
| 2555 | DTP02 = D8 | |
| 2556 | 9 | |
| 2557 | Mammograph y Certifi cation Qua lifier | |
| 2558 | 2 A/N | |
| 2559 | 837: (P) 2 300 REF01( 6) | |
| 2560 | Print: N/A | |
| 2561 | Biller Inp ut: N/A | |
| 2562 | Storage: N /A | |
| 2563 | Note: Alwa ys EW. | |
| 2564 | ||
| 2565 | 10 | |
| 2566 | Initial Tr eatment DT Qualifier | |
| 2567 | 3 A/N | |
| 2568 | 837: (P) 2 300 DTP01 | |
| 2569 | Print: N/A | |
| 2570 | Biller Inp ut: N/A | |
| 2571 | Storage: N /A | |
| 2572 | Note: Alwa ys 454. | |
| 2573 | ||
| 2574 | 11 | |
| 2575 | Last X-Ray DT Qualif ier | |
| 2576 | 3 A/N | |
| 2577 | 837: (P) 2 300 DTP01 | |
| 2578 | Print: N/A | |
| 2579 | Biller Inp ut: N/A | |
| 2580 | Storage: N /A | |
| 2581 | Note: Alwa ys 455 | |
| 2582 | ||
| 2583 | 12 | |
| 2584 | Acute Mani festation DT Qualifi er (453) | |
| 2585 | 3 A/N | |
| 2586 | 837: (P) 2 300 DTP01 | |
| 2587 | Print: N/A | |
| 2588 | Biller Inp ut: N/A | |
| 2589 | Storage: N /A | |
| 2590 | ||
| 2591 | 13 | |
| 2592 | Code List Qualifier Code (DR) | |
| 2593 | 2 A/N | |
| 2594 | 837: (I) 2 300 HI01 - 1 | |
| 2595 | Print: N/A | |
| 2596 | Biller Inp ut: N/A | |
| 2597 | Storage: N /A | |
| 2598 | Note: Alwa ys DR | |
| 2599 | ||
| 2600 | 14 | |
| 2601 | Industry C ode | |
| 2602 | (Prospecti ve Payment Sys. DRG) ) | |
| 2603 | 10 A/N | |
| 2604 | ||
| 2605 | 837: (I) 2 300 HI01 – 2 | |
| 2606 | Print: | |
| 2607 | UB04 – FL7 1 | |
| 2608 | Biller Inp ut: | |
| 2609 | Screen 4 S ection 3 | |
| 2610 | Screen 10 Section 1 | |
| 2611 | Storage: | |
| 2612 | File: BILL /CLAIMS (# 399) | |
| 2613 | Field: PPS (#170) | |
| 2614 | ||
| 2615 | 15 | |
| 2616 | Code List Qualifier Code – Adm it DX | |
| 2617 | 3 A/N | |
| 2618 | 837: (I) 2 300 HI02 – 1 | |
| 2619 | Print: N/A | |
| 2620 | Biller Inp ut: N/A | |
| 2621 | Storage: N /A | |
| 2622 | Note: Alwa ys BJ with ICD 9 | |
| 2623 | Always ABJ with ICD 10 | |
| 2624 | ||
| 2625 | 16 | |
| 2626 | Industry C ode - (Adm itting DX) | |
| 2627 | 10 A/N | |
| 2628 | 837: (I) 2 300 HI02 – 2 | |
| 2629 | Print: UB0 4 – FL69 | |
| 2630 | Biller Inp ut: | |
| 2631 | Screen 4 S ection 3 | |
| 2632 | Screen 10 Section 1 | |
| 2633 | Storage: | |
| 2634 | File: BILL /CLAIMS (# 399) | |
| 2635 | Field: ADM ITTING DIA GNOSIS (#2 15) | |
| 2636 | ||
| 2637 | 17 | |
| 2638 | Code List Qualifier Code (Pati ent Reason for Visit ) 01 | |
| 2639 | 3 A/N | |
| 2640 | 837: (I) 2 300 HI02 – 1 | |
| 2641 | Print: N/A | |
| 2642 | Biller Inp ut: N/A | |
| 2643 | Storage: N /A | |
| 2644 | Note: Alwa ys PR with ICD 9 | |
| 2645 | Always APR with ICD 10 | |
| 2646 | ||
| 2647 | 18 | |
| 2648 | Industry C ode (Patie nt Reason for Visit 01) | |
| 2649 | 10 A/N | |
| 2650 | 837: (I) 2 300 HI02 – 2 | |
| 2651 | Print: | |
| 2652 | UB04 – FL7 0 (Box 1) | |
| 2653 | Biller Inp ut: Screen 10 Sectio n 2 | |
| 2654 | Storage: | |
| 2655 | File: BILL /CLAIMS (# 399) | |
| 2656 | Field: PRV DIAGNOSIS (1) (#249 ) | |
| 2657 | None | |
| 2658 | 19 | |
| 2659 | Code List Qualifier Code (Pati ent Reason for Visit ) 02 | |
| 2660 | 3 A/N | |
| 2661 | 837: (I) 2 300 HI02 – 1 | |
| 2662 | Print: N/A | |
| 2663 | Biller Inp ut: N/A | |
| 2664 | Storage: N /A | |
| 2665 | Note: Alwa ys PR with ICD 9 | |
| 2666 | Always APR with ICD 10 | |
| 2667 | ||
| 2668 | ||
| 2669 | 20 | |
| 2670 | Industry C ode (Patie nt Reason for Visit) 02 | |
| 2671 | 10 A/N | |
| 2672 | 837: (I) 2 300 HI02 – 2 | |
| 2673 | Print: | |
| 2674 | UB04 – FL7 0 (Box 2) | |
| 2675 | Biller Inp ut: Screen 10 Sectio n 2 | |
| 2676 | Storage: | |
| 2677 | File: BILL /CLAIMS (# 399) | |
| 2678 | Field: PRV DIAGNOSIS (2) (#250 ) | |
| 2679 | ||
| 2680 | 21 | |
| 2681 | Code List Qualifier Code (Pati ent Reason for Visit ) 03 | |
| 2682 | 3 A/N | |
| 2683 | 837: (I) 2 300 HI02 – 1 | |
| 2684 | Print: N/A | |
| 2685 | Biller Inp ut: N/A | |
| 2686 | Storage: N /A | |
| 2687 | Note: Alwa ys PR with ICD 9 | |
| 2688 | Always APR with ICD 10 | |
| 2689 | ||
| 2690 | 22 | |
| 2691 | Industry C ode | |
| 2692 | (Patient R eason for Visit) 03 | |
| 2693 | 10 A/N | |
| 2694 | 837: (I) 2 300 HI02 – 2 | |
| 2695 | Print: | |
| 2696 | UB04 – FL7 0 (Box 3) | |
| 2697 | Biller Inp ut: Screen 10 Sectio n 2 | |
| 2698 | Storage: | |
| 2699 | File: BILL /CLAIMS (# 399) | |
| 2700 | Field: PRV DIAGNOSIS (3) (#251 ) | |
| 2701 | ||
| 2702 | 23 | |
| 2703 | Disability Date Qual ifier | |
| 2704 | 3 A/N | |
| 2705 | 837: (P) 2 300 DTP01( 9) | |
| 2706 | Print: N/A | |
| 2707 | Biller Inp ut: N/A | |
| 2708 | Storage: N /A | |
| 2709 | Qualifiers : 360 – St art date; 361 – End date; 314 – Disabili ty span | |
| 2710 | 24 | |
| 2711 | Disability Dates | |
| 2712 | 17 A/N CCY YMMDD or C CYYMMDD-CC YYMMDD | |
| 2713 | 837: (P) 2 300 DTP03( 9) | |
| 2714 | Print: N/A | |
| 2715 | Biller Inp ut: Screen 8 Section 5 | |
| 2716 | Storage: | |
| 2717 | File: BILL /CLAIMS (# 399) | |
| 2718 | Field: DIS ABILITY ST ART DATE ( #263) | |
| 2719 | Field: DIS ABILITY EN D DATE (#2 64) | |
| 2720 | If DTP01 = 360 or 36 1 then DTP 02=D8 and format is CCYYMMDD | |
| 2721 | If DTP01 = 314 then DTP02 = RD 8 and form at is CCYY MMDD-CCYYM MDD | |
| 2722 | 25 | |
| 2723 | Assume Car e Date Qua lifier | |
| 2724 | 3 A/N | |
| 2725 | 837: (P) 2 300 DTP01( 14) | |
| 2726 | Print: N/A | |
| 2727 | Biller Inp ut: N/A | |
| 2728 | Storage: N /A | |
| 2729 | 90 Assume Care | |
| 2730 | 26 | |
| 2731 | Assume Car e Date | |
| 2732 | 8 N | |
| 2733 | CCYYMMDD | |
| 2734 | 837: (P) 2 300 DTP03( 14) | |
| 2735 | Print: N/A | |
| 2736 | Biller Inp ut: Screen 8 Section 6 | |
| 2737 | Storage: | |
| 2738 | File: BILL /CLAIMS (# 399) | |
| 2739 | Field: ASS UMED CARE DATE (#282 ) | |
| 2740 | DTP02 = D8 | |
| 2741 | 27 | |
| 2742 | Relinquish Care Date Qualifier | |
| 2743 | 3 A/N | |
| 2744 | 837: (P) 2 300 DTP01( 14) | |
| 2745 | Print: N/A | |
| 2746 | Biller Inp ut: N/A | |
| 2747 | Storage: N /A | |
| 2748 | 91 Relinqu ish care | |
| 2749 | 28 | |
| 2750 | Relinquish Care Date | |
| 2751 | 8 N | |
| 2752 | CCYYMMDD | |
| 2753 | 837: (P) 2 300 DTP03( 14) | |
| 2754 | Print: N/A | |
| 2755 | Biller Inp ut: Screen 8 Section 6 | |
| 2756 | Storage: | |
| 2757 | File: BILL /CLAIMS (# 399) | |
| 2758 | Field: REL INQUISHED CAREDATE ( #283) | |
| 2759 | DTP02 = D8 | |
| 2760 | 29 | |
| 2761 | Property a nd Casualt y Date Qua lifier | |
| 2762 | 3 N | |
| 2763 | 837: (P) D TP01(15) | |
| 2764 | Print: N/A | |
| 2765 | Biller Inp ut: N/A | |
| 2766 | Storage: N /A | |
| 2767 | Note: Alwa ys 444 | |
| 2768 | ||
| 2769 | 30 | |
| 2770 | Property a nd Casualt y Date of First Cont act | |
| 2771 | 8 N CCYYMM DD | |
| 2772 | 837: (P) 2 300 DTP03( 15) | |
| 2773 | Print: N/A | |
| 2774 | Biller Inp ut: Screen 8 Section 2 | |
| 2775 | Storage: | |
| 2776 | File: BILL /CLAIMS (# 399) | |
| 2777 | Field: REL INQUISHED CARE DATE (#283) | |
| 2778 | DTP02 = D8 | |
| 2779 | ||
| 2780 | ||
| 2781 | CL1B – Loo p 2300 (Cl aim Level Data) [SEQ 52] | |
| 2782 | (OPTIONAL – Max len gth 44 byt es) | |
| 2783 | Piece | |
| 2784 | Descriptio n | |
| 2785 | Max Length Data Type | |
| 2786 | 837/Print Location | |
| 2787 | VistA Inpu t/Storage | |
| 2788 | FSC Proces sing Comme nts | |
| 2789 | 1 | |
| 2790 | RECORD ID = ‘CL1B ’ | |
| 2791 | 4 A | |
| 2792 | ||
| 2793 | ||
| 2794 | ||
| 2795 | 2 | |
| 2796 | Attachment Report Ty pe | |
| 2797 | 2 A | |
| 2798 | 837: 2300 PWK01 | |
| 2799 | Print: | |
| 2800 | CMS 1500 – Box 19 | |
| 2801 | Note: Prin ts only wh en Rate Ty pe = Worke r’s Comp. | |
| 2802 | Biller Inp ut: Screen 8 Section 4 | |
| 2803 | Storage: | |
| 2804 | File: BILL /CLAIMS (# 399) | |
| 2805 | Field: ATT ACHMENT RE PORT TYPE (#285) | |
| 2806 | None | |
| 2807 | 3 | |
| 2808 | Attachment Report Tr ansmission Code | |
| 2809 | 2 A | |
| 2810 | 837: 2300 PWK02 | |
| 2811 | Print: CMS 1500 – Bo x 19 | |
| 2812 | Note: Prin ts only wh en Rate Ty pe = Worke r’s Comp. | |
| 2813 | Biller Inp ut: Screen 8 Section 4 | |
| 2814 | Storage: | |
| 2815 | File: BILL /CLAIMS (# 399) | |
| 2816 | Field: ATT ACHMENT RE PORT TRANS CODE (#28 6) | |
| 2817 | None | |
| 2818 | 4 | |
| 2819 | Attachment Control Q ualifier | |
| 2820 | 2 A | |
| 2821 | 837: 2300 PWK05 | |
| 2822 | Print: N/A | |
| 2823 | Biller Inp ut: N/A | |
| 2824 | Storage: N /A | |
| 2825 | Note: Alwa ys AC | |
| 2826 | ||
| 2827 | 5 | |
| 2828 | Attachment Control N umber | |
| 2829 | 30 A/N | |
| 2830 | 837: 2300 PWK06 | |
| 2831 | Print: CMS 1500 – Bo x 19 | |
| 2832 | Note: Prin ts only wh en Rate Ty pe = Worke r’s Comp. | |
| 2833 | Biller Inp ut: Screen 8 Section 4 | |
| 2834 | Storage: | |
| 2835 | File: BILL /CLAIMS (# 399) | |
| 2836 | Field: ATT ACHMENT CO NTROL NUMB ER (#284) | |
| 2837 | None | |
| 2838 | ||
| 2839 | SUB - Loop 2310C/D/E 2300 (Ser vice Facil ity Data) [SEQ 55] | |
| 2840 | (OPTIONAL – Max len gth 210 by tes) | |
| 2841 | Piece | |
| 2842 | Descriptio n | |
| 2843 | Max Length Data Type | |
| 2844 | 837/Print Location | |
| 2845 | VistA Inpu t/Storage | |
| 2846 | FSC Proces sing Comme nts | |
| 2847 | 1 | |
| 2848 | RECORD ID = ‘SUB ‘ | |
| 2849 | 4 A | |
| 2850 | ||
| 2851 | ||
| 2852 | ||
| 2853 | 2 | |
| 2854 | Lab/Facili ty Name | |
| 2855 | 30 A/N | |
| 2856 | 837: | |
| 2857 | (I) 2310E NM103 | |
| 2858 | (P) 2310C NM103 | |
| 2859 | Print: | |
| 2860 | CMS 1500 – Box 32 – Line 1 | |
| 2861 | Biller Inp ut: | |
| 2862 | Non-fee: I f the divi sion on a claim has no NPI (i. e. mobile unit), the Billing P rovider wi ll be the parent and the mobil e unit wil l become t he Service Facility. This inf ormation i s taken fr om the Ins titution f ile. | |
| 2863 | Fee: Scree n 10 Secti on 4 | |
| 2864 | Users may add an Out side Facil ity to a c laim but t he facilit y is defin ed in SYST PROVNF of Provider I D Maintena nce | |
| 2865 | Storage: | |
| 2866 | File: IB N ON/OTHER V A BILLING PROVIDER ( #355.93) | |
| 2867 | Field: NAM E (#.01) | |
| 2868 | File: BILL /CLAIMS (# 399) | |
| 2869 | Field: NON -VA FACILI TY (#232) | |
| 2870 | 837P Loop Change to 2310C. | |
| 2871 | NM101 mapp ed from SU B2 piece 2 | |
| 2872 | NM102 mapp ed from SU B2 piece 3 | |
| 2873 | ||
| 2874 | HIPAA maxi mum length increased to 60 in 5010. | |
| 2875 | 3 | |
| 2876 | Lab/Facili ty Address 1 | |
| 2877 | 35 A/N | |
| 2878 | 837: | |
| 2879 | (P) 2310C N301 | |
| 2880 | (I) 2310E N301 | |
| 2881 | Print: | |
| 2882 | CMS 1500 – Box 32 – Line 2 | |
| 2883 | Biller Inp ut: Fee: S creen 10 S ection 4 | |
| 2884 | Users may add an Out side Facil ity to a c laim but t he facilit y is defin ed in SYST PROVNF of Provider I D Maintena nce | |
| 2885 | Storage: | |
| 2886 | File: IB N ON/OTHER V A BILLING PROVIDER ( #355.93) | |
| 2887 | Field: STR EET ADDRES S (#.05) | |
| 2888 | 837P Loop Change to 2310C. | |
| 2889 | 4 | |
| 2890 | Lab/Facili ty City | |
| 2891 | 30 A/N | |
| 2892 | 837: | |
| 2893 | (P) 2310C N401 | |
| 2894 | (I) 2310E N401 | |
| 2895 | Print: | |
| 2896 | CMS 1500 – Box 32 – Line 3 | |
| 2897 | Biller Inp ut: Fee: S creen 10 S ection 4 | |
| 2898 | Users may add an Out side Facil ity to a c laim but t he facilit y is defin ed in SYST PROVNF of Provider I D Maintena nce | |
| 2899 | Storage: | |
| 2900 | File: IB N ON/OTHER V A BILLING PROVIDER ( #355.93) | |
| 2901 | Field: CIT Y (#.06) | |
| 2902 | 837P Loop Change to 2310C Requ ired when in US or t erritories . | |
| 2903 | 5 | |
| 2904 | Lab/Facili ty State | |
| 2905 | 2 A/N | |
| 2906 | 837: | |
| 2907 | P) 2310C N 402 | |
| 2908 | (I) 2310E/ N4/02 | |
| 2909 | Print: | |
| 2910 | CMS 1500 – Box 32 – Line 3 | |
| 2911 | Biller Inp ut: Fee: S creen 10 S ection 4 | |
| 2912 | Users may add an Out side Facil ity to a c laim but t he facilit y is defin ed in SYST PROVNF of Provider I D Maintena nce | |
| 2913 | Storage: | |
| 2914 | File: IB N ON/OTHER V A BILLING PROVIDER ( #355.93) | |
| 2915 | Field: STA TE (#.07) | |
| 2916 | 837P Loop Change to 2310C Requ ired when in US or t erritories . | |
| 2917 | 6 | |
| 2918 | Lab/Facili ty ZIP Cod e | |
| 2919 | 15 N | |
| 2920 | 837: | |
| 2921 | (P) 2310C N403 | |
| 2922 | (I) 2310E N403 | |
| 2923 | Print: | |
| 2924 | CMS 1500 – Box 32 – Line 3 | |
| 2925 | Biller Inp ut: Fee: S creen 10 S ection 4 | |
| 2926 | Users may add an Out side Facil ity to a c laim but t he facilit y is defin ed in SYST PROVNF of Provider I D Maintena nce | |
| 2927 | Storage: | |
| 2928 | File: IB N ON/OTHER V A BILLING PROVIDER ( #355.93) | |
| 2929 | Field: ZIP CODE (#.0 8) | |
| 2930 | 837P Loop Change to 2310C Requ ired when in US or t erritories . | |
| 2931 | 7 | |
| 2932 | Total Purc hased Serv ice Amt | |
| 2933 | 15 N | |
| 2934 | 2 Decimals | |
| 2935 | 837: Print only | |
| 2936 | Print: | |
| 2937 | CMS 1500 – Box 20 | |
| 2938 | Biller Inp ut: N/A | |
| 2939 | This amoun t is calcu lated from the amoun ts entered for each purchased line item. | |
| 2940 | Storage: | |
| 2941 | File: BILL /CLAIMS (# 399) | |
| 2942 | Subfile: P ROCEDURES (#304) | |
| 2943 | Field: PUR CHASED COS T (#19) | |
| 2944 | Element de leted. Pri nt Field | |
| 2945 | 8 | |
| 2946 | CLIA # | |
| 2947 | (Clinical Laboratory Improveme nt Amendme nt Number) | |
| 2948 | 10 A/N | |
| 2949 | ||
| 2950 | 837: | |
| 2951 | (P) 2300 R EF02 | |
| 2952 | Print: | |
| 2953 | CMS 1500 – BOX 23 | |
| 2954 | Biller Inp ut: Screen 10 Sectio n 4 | |
| 2955 | Storage: | |
| 2956 | File: BILL /CLAIMS (# 399) | |
| 2957 | Field: LAB CLIA NUMB ER (#235) | |
| 2958 | Note: The non-VA CLI A# is stor ed with th e non-VA F acility – SYSTPROVNF of Provid er ID Main tenance. T he VA CLIA # is store d in the I nstitution file. | |
| 2959 | Set REF01= X4 | |
| 2960 | ||
| 2961 | 9 | |
| 2962 | BLANK | |
| 2963 | 1 | |
| 2964 | ||
| 2965 | ||
| 2966 | ||
| 2967 | 10 | |
| 2968 | Purchased Serv Flag | |
| 2969 | 1 = FEE,NO N-LAB | |
| 2970 | 2 = FEE, L AB | |
| 2971 | ||
| 2972 | 1 N | |
| 2973 | ||
| 2974 | Note: Used by FSC to determine where to output the rendering provider informatio n if care was render ed at othe r than the main faci lity site. | |
| 2975 | Biller Inp ut: Screen 10 Sectio n 4 | |
| 2976 | Storage: | |
| 2977 | File: BILL /CLAIMS (# 399) | |
| 2978 | Field: NON -VA CARE T YPE (#233) | |
| 2979 | None | |
| 2980 | 11 | |
| 2981 | BLANK | |
| 2982 | 1 | |
| 2983 | ||
| 2984 | ||
| 2985 | ||
| 2986 | 12 | |
| 2987 | Lab/Facili ty Address 2 | |
| 2988 | 50 A/N | |
| 2989 | 837: | |
| 2990 | (I) 2310E N302 | |
| 2991 | (P)2310C N 302 | |
| 2992 | Print: N/A | |
| 2993 | Biller Inp ut: Fee: S creen 10 S ection 4 | |
| 2994 | Users may add an Out side Facil ity to a c laim but t he facilit y is defin ed in SYST PROVNF of Provider I D Maintena nce | |
| 2995 | Storage: | |
| 2996 | File: IB N ON/OTHER V A BILLING PROVIDER ( #355.93) | |
| 2997 | Field: STR EET ADDRES S LINE 2 ( #.1) | |
| 2998 | 837P: Loop change to 2310C. | |
| 2999 | ||
| 3000 | ||
| 3001 | SUB2 - Loo p 2310C/E (Service F acility Da ta) [SEQ 5 7] | |
| 3002 | (OPTIONAL – Max len gth 178 b ytes) | |
| 3003 | Piece | |
| 3004 | Descriptio n | |
| 3005 | Max Length | |
| 3006 | Data Type | |
| 3007 | 837/Print Location | |
| 3008 | VistA Inpu t/Storage | |
| 3009 | FSC Proces sing Comme nts | |
| 3010 | 1 | |
| 3011 | RECORD ID = ‘SUB2 ‘ | |
| 3012 | 4 A | |
| 3013 | N/A | |
| 3014 | ||
| 3015 | ||
| 3016 | 2 | |
| 3017 | Lab/Facili ty Entity Code | |
| 3018 | ||
| 3019 | 2 A | |
| 3020 | 837: | |
| 3021 | (I) 2310E NM101 | |
| 3022 | (P) 2310C/ NM101 | |
| 3023 | Print: N/A | |
| 3024 | Biller Inp ut: | |
| 3025 | Fee: Scree n 10 Secti on 4 | |
| 3026 | Users may add an Out side Facil ity to a claim but the facili ty is defi ned in SYS TPROVNF of Provider ID Mainten ance. No matter wha t value a user enter s for X12 TYPE OF FA CILITY, 77 will be t ransmitted . | |
| 3027 | Storage: | |
| 3028 | File: IB N ON/OTHER V A BILLING PROVIDER ( #355.93) | |
| 3029 | Field: X12 TYPE OF F ACILITY (# .11) | |
| 3030 | 837P: Loop change to 2310C. | |
| 3031 | 837I: Code change fr om FA to 7 7. | |
| 3032 | 3 | |
| 3033 | Lab/Facili ty Entity Type Quali fier | |
| 3034 | 2 = Non-Pe rson | |
| 3035 | 1 N | |
| 3036 | 837: | |
| 3037 | (I) 2310E NM102 | |
| 3038 | (P) 2310C NM102 | |
| 3039 | Print: N/A | |
| 3040 | Biller Inp ut: N/A | |
| 3041 | Storage: N /A | |
| 3042 | 837P: Loop change to 2310C. | |
| 3043 | ||
| 3044 | 4 | |
| 3045 | BLANK | |
| 3046 | 1 | |
| 3047 | ||
| 3048 | ||
| 3049 | ||
| 3050 | 5 | |
| 3051 | Lab/Facili ty Primary ID Qualif ier | |
| 3052 | 2 A/N | |
| 3053 | 837: | |
| 3054 | (P) 2310C NM108 | |
| 3055 | (I) 2310E NM108 | |
| 3056 | Print: N/A | |
| 3057 | Biller Inp ut: N/A | |
| 3058 | Storage: N /A | |
| 3059 | Note: Alwa ys XX | |
| 3060 | ||
| 3061 | 6 | |
| 3062 | Lab/Facili ty Primary ID | |
| 3063 | 20 A/N | |
| 3064 | 837: | |
| 3065 | (P) 2310C NM109 | |
| 3066 | (I) 2310E NM109 | |
| 3067 | Print: | |
| 3068 | CMS 1500 – Box 32a | |
| 3069 | Biller Inp ut: | |
| 3070 | Fee: Scree n 10 Secti on 4 | |
| 3071 | Users may add an Out side Facil ity to a claim but the facili ty is defi ned in SYS TPROVNF of Provider ID Mainten ance. The NPI becom es the Pri mary ID. | |
| 3072 | Storage: | |
| 3073 | File: IB N ON/OTHER V A BILLING PROVIDER ( #355.93) | |
| 3074 | Field: NPI (#41.01) | |
| 3075 | ||
| 3076 | 7 | |
| 3077 | Lab/Facili ty Seconda ry ID Qual ifier (1) | |
| 3078 | 2 A/N | |
| 3079 | 837: | |
| 3080 | (I) 2310E REF01 | |
| 3081 | (P) 2310C REF01 | |
| 3082 | Print: | |
| 3083 | CMS 1500 – Box 32b | |
| 3084 | Biller Inp ut: | |
| 3085 | Fee: Scree n 10 Secti on 4 | |
| 3086 | Users may add an Out side Facil ity to a claim but the facili ty is defi ned in SYS TPROVNF of Provider ID Mainten ance. Sec ondary IDs can be th e provider ’s own ID or an ID a ssigned by a payer. | |
| 3087 | Storage: | |
| 3088 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 3089 | Field: PRO VIDER ID T YPE (#.06) | |
| 3090 | 837P: Loop change to 2310C. | |
| 3091 | ||
| 3092 | Code set c hange for both 837I and P - no w only 0B, LU and G2 are allow ed. | |
| 3093 | 8 | |
| 3094 | Lab/Facili ty Seconda ry ID (1) | |
| 3095 | 20 A/N | |
| 3096 | 837: | |
| 3097 | (I) 2310E REF02 | |
| 3098 | (P) 2310C REF02 | |
| 3099 | Print: | |
| 3100 | CMS 1500 – Box 32b | |
| 3101 | Biller Inp ut: | |
| 3102 | Fee: Scree n 10 Secti on 4 | |
| 3103 | Storage: | |
| 3104 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 3105 | Field: PRO VIDER ID ( #.07) | |
| 3106 | 837P: Loop change to 2310C. | |
| 3107 | 9 | |
| 3108 | Lab/Facili ty Seconda ry ID Qual ifier (2) | |
| 3109 | 2 A/N | |
| 3110 | 837: | |
| 3111 | (I) 2310E REF01 | |
| 3112 | (P) 2310C REF01 | |
| 3113 | Print: N/A | |
| 3114 | Biller Inp ut: | |
| 3115 | Fee: Scree n 10 Secti on 4 | |
| 3116 | Users may add an Out side Facil ity to a claim but the facili ty is defi ned in SYS TPROVNF of Provider ID Mainten ance. Sec ondary IDs can be th e provider ’s own ID or an ID a ssigned by a payer. | |
| 3117 | Storage: | |
| 3118 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 3119 | Field: PRO VIDER ID T YPE (#.06) | |
| 3120 | 837P: Loop change to 2310C. | |
| 3121 | ||
| 3122 | Code set c hange for both 837I and P - no w only 0B, LU and G2 are allow ed. | |
| 3123 | 10 | |
| 3124 | Lab/Facili ty Seconda ry ID (2) | |
| 3125 | 20 A/N | |
| 3126 | 837: | |
| 3127 | (I) 2310E REF02 | |
| 3128 | (P) 2310C REF02 | |
| 3129 | Print: N/A | |
| 3130 | Biller Inp ut: | |
| 3131 | Fee: Scree n 10 Secti on 4 | |
| 3132 | Storage: | |
| 3133 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 3134 | Field: PRO VIDER ID ( #.07) | |
| 3135 | 837P: Loop change to 2310C. | |
| 3136 | ||
| 3137 | 11 | |
| 3138 | Lab/Facili ty Seconda ry ID Qual ifier (3) | |
| 3139 | 2 A/N | |
| 3140 | 837: | |
| 3141 | (I) 2310E REF01 | |
| 3142 | (P) 2310C REF01 | |
| 3143 | Print: N/A | |
| 3144 | Biller Inp ut: | |
| 3145 | Fee: Scree n 10 Secti on 4 | |
| 3146 | Users may add an Out side Facil ity to a claim but the facili ty is defi ned in SYS TPROVNF of Provider ID Mainten ance. Sec ondary IDs can be th e provider ’s own ID or an ID a ssigned by a payer. | |
| 3147 | Storage: | |
| 3148 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 3149 | Field: PRO VIDER ID T YPE (#.06) | |
| 3150 | 837P: Loop change to 2310C. | |
| 3151 | ||
| 3152 | Code set c hange for both 837I and P - no w only 0B, LU and G2 are allow ed. | |
| 3153 | 12 | |
| 3154 | Lab/Facili ty Seconda ry ID (3) | |
| 3155 | 20 A/N | |
| 3156 | 837: | |
| 3157 | (I) 2310E REF02 | |
| 3158 | (P) 2310C REF02 | |
| 3159 | Print: N/A | |
| 3160 | Biller Inp ut: | |
| 3161 | Fee: Scree n 10 Secti on 4 | |
| 3162 | Storage: | |
| 3163 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 3164 | Field: PRO VIDER ID ( #.07) | |
| 3165 | 837P: Loop change to 2310C. | |
| 3166 | ||
| 3167 | ||
| 3168 | UB1 - Loop 2300 (Cla im Level F orm Data) [SEQ 60] | |
| 3169 | (OPTIONAL – Max len gth 212 b ytes | |
| 3170 | Piece | |
| 3171 | Descriptio n | |
| 3172 | Max Length | |
| 3173 | Data Type | |
| 3174 | 837/Print Location | |
| 3175 | VistA Inpu t/Storage | |
| 3176 | FSC Proces sing Comme nts | |
| 3177 | 1 | |
| 3178 | RECORD ID = ‘UB1 ’ | |
| 3179 | 4 A | |
| 3180 | ||
| 3181 | ||
| 3182 | ||
| 3183 | 2 | |
| 3184 | Certificat ion Condit ion Indica tor (Homeb ound) | |
| 3185 | 1 A | |
| 3186 | 837: (P) 2 300 CRC02 | |
| 3187 | Print: N/A | |
| 3188 | Biller Inp ut: Screen 8 Section 7 | |
| 3189 | Storage: | |
| 3190 | File: BILL /CLAIMS (# 399) | |
| 3191 | Field: HOM EBOUND (#2 36) | |
| 3192 | Set CRC01 = 75 | |
| 3193 | 3 | |
| 3194 | Special Pr ogram Indi cator | |
| 3195 | 2 A/N | |
| 3196 | 837: (P) 2 300 CLM12 | |
| 3197 | Print: N/A | |
| 3198 | ||
| 3199 | Biller Inp ut: Screen 8 Section 7 | |
| 3200 | Storage: | |
| 3201 | File: BILL /CLAIMS (# 399) | |
| 3202 | Field: SPE CIAL PROGR AM INDICAT OR (#238) | |
| 3203 | Note: Alwa ys 31 for Medicare W NR | |
| 3204 | Only codes 02, 03, 0 5 and 09 a llowed. | |
| 3205 | Codes 01, 07 and 08 have been deleted. | |
| 3206 | ||
| 3207 | 4 | |
| 3208 | Last Seen DT | |
| 3209 | 8 N | |
| 3210 | CCYYMMDD | |
| 3211 | 837: (P) 2 300 DTP03 (3) | |
| 3212 | Print: | |
| 3213 | ||
| 3214 | Biller Inp ut: Screen 8 Section 7 | |
| 3215 | Storage: | |
| 3216 | File: BILL /CLAIMS (# 399) | |
| 3217 | Field: DAT E LAST SEE N (#237) | |
| 3218 | DTP01 = 30 4 | |
| 3219 | DTP02 = D8 | |
| 3220 | 5 | |
| 3221 | BLANK | |
| 3222 | 1 | |
| 3223 | ||
| 3224 | ||
| 3225 | ||
| 3226 | 6 | |
| 3227 | BLANK | |
| 3228 | 1 | |
| 3229 | ||
| 3230 | ||
| 3231 | ||
| 3232 | 7 | |
| 3233 | BLANK | |
| 3234 | 1 | |
| 3235 | ||
| 3236 | ||
| 3237 | ||
| 3238 | 8 | |
| 3239 | BLANK | |
| 3240 | 1 | |
| 3241 | ||
| 3242 | ||
| 3243 | ||
| 3244 | 9 | |
| 3245 | BLANK | |
| 3246 | 1 | |
| 3247 | ||
| 3248 | ||
| 3249 | ||
| 3250 | 10 | |
| 3251 | BLANK | |
| 3252 | 1 | |
| 3253 | ||
| 3254 | ||
| 3255 | ||
| 3256 | 11 | |
| 3257 | BLANK | |
| 3258 | 1 | |
| 3259 | ||
| 3260 | ||
| 3261 | ||
| 3262 | 12 | |
| 3263 | BLANK | |
| 3264 | 1 | |
| 3265 | ||
| 3266 | ||
| 3267 | ||
| 3268 | 13 | |
| 3269 | BLANK | |
| 3270 | 1 | |
| 3271 | ||
| 3272 | ||
| 3273 | ||
| 3274 | 14 | |
| 3275 | BLANK | |
| 3276 | 1 | |
| 3277 | ||
| 3278 | ||
| 3279 | ||
| 3280 | 15 | |
| 3281 | BLANK | |
| 3282 | 1 | |
| 3283 | ||
| 3284 | ||
| 3285 | ||
| 3286 | 16 | |
| 3287 | BLANK | |
| 3288 | 1 | |
| 3289 | ||
| 3290 | ||
| 3291 | ||
| 3292 | 17 | |
| 3293 | BLANK | |
| 3294 | 1 | |
| 3295 | ||
| 3296 | ||
| 3297 | ||
| 3298 | 18 | |
| 3299 | BLANK | |
| 3300 | 1 | |
| 3301 | ||
| 3302 | ||
| 3303 | ||
| 3304 | 19 | |
| 3305 | Claim Note Text | |
| 3306 | 80 A/N | |
| 3307 | 837: (P) 2 300 NTE02 | |
| 3308 | Print: | |
| 3309 | CMS 1500 – Box 19 | |
| 3310 | Biller Inp ut: Screen 10 Sectio n 6 | |
| 3311 | Storage: | |
| 3312 | File: BILL /CLAIMS (# 399) | |
| 3313 | Field: FOR M LOC 19-U NSPECIFIED DATA (#45 9) | |
| 3314 | Set NTE01 = ADD | |
| 3315 | 20 | |
| 3316 | Billing No te Text Qu alifier | |
| 3317 | ||
| 3318 | 3 A/N | |
| 3319 | 837: (I) 2 300 NTE01 | |
| 3320 | Print: N/A | |
| 3321 | Biller Inp ut: N/A | |
| 3322 | Storage: N /A | |
| 3323 | Only codes ALG, DCP, DGN, DME, MED, NTR, ODT, RHB, RLH, RNH, SET, SFM, SPT, UPI | |
| 3324 | 21 | |
| 3325 | Billing No te Text | |
| 3326 | 80 A/N | |
| 3327 | 837: (I) 2 300 NTE02 | |
| 3328 | Print: | |
| 3329 | UB04 – FL 80 | |
| 3330 | Biller Inp ut: Screen 10 Sectio n 1 | |
| 3331 | Storage: | |
| 3332 | File: BILL /CLAIMS (# 399) | |
| 3333 | Field: BIL L REMARKS (#402) | |
| 3334 | ||
| 3335 | ||
| 3336 | OC1-OC12 - Loop 2300 (Occurren ce Code Da ta) [SEQ 6 5] | |
| 3337 | Inpatient only - one or more r ecords per Claim Dat a record s et - may r epeat 1-12 | |
| 3338 | (OPTIONAL – Max len gth 17 byt es) | |
| 3339 | Piece | |
| 3340 | Descriptio n | |
| 3341 | Max Length | |
| 3342 | Data Type | |
| 3343 | 837/Print Location | |
| 3344 | VistA Inpu t/Storage | |
| 3345 | FSC Proces sing Comme nts | |
| 3346 | 1 | |
| 3347 | RECORD ID = ‘OC1 ’ - ‘OC12’ | |
| 3348 | 4 A | |
| 3349 | ||
| 3350 | ||
| 3351 | ||
| 3352 | 2 | |
| 3353 | Occurrence Code DT | |
| 3354 | 8 N CCYYMM DD | |
| 3355 | 837: (I) 2 300 HI01 - 4 | |
| 3356 | Print: | |
| 3357 | UB04 – FL3 1-34 | |
| 3358 | Biller Inp ut: Screen 4/5 Secti on 6/7 | |
| 3359 | Storage: | |
| 3360 | File: BILL /CLAIMS (# 399) | |
| 3361 | Subfile: O CCURRENCE CODE (#41) | |
| 3362 | Field: DAT E (#.02) | |
| 3363 | Set HI01- 3 = D8 | |
| 3364 | 3 | |
| 3365 | OCCURRENCE CODE | |
| 3366 | 3 A/N | |
| 3367 | 837: (I) 2 300 HI01 - 2 | |
| 3368 | Print: | |
| 3369 | UB04 – FL3 1-34 | |
| 3370 | Biller Inp ut: Screen 4/5 Secti on 6/7 | |
| 3371 | Storage: | |
| 3372 | File: BILL /CLAIMS (# 399) | |
| 3373 | Subfile: O CCURRENCE CODE (#41) | |
| 3374 | Field: OCC URRENCE CO DE (#.01) | |
| 3375 | Set HI01-1 = BH | |
| 3376 | OS1-OS12 - Loop 2300 (Occurren ce Span Co de Data) [ SEQ 70] | |
| 3377 | Inpatient only - one or more r ecords per Claim Dat a record - may repea t 1-12 | |
| 3378 | (OPTIONAL – Max len gth 26 byt es) | |
| 3379 | Piece | |
| 3380 | Descriptio n | |
| 3381 | Max Length | |
| 3382 | Data Type | |
| 3383 | 837/Print Location | |
| 3384 | VistA Inpu t/Storage | |
| 3385 | FSC Proces sing Comme nts | |
| 3386 | 1 | |
| 3387 | RECORD ID = ‘OS1 ’ - ‘OS12’ | |
| 3388 | 4 A | |
| 3389 | ||
| 3390 | ||
| 3391 | ||
| 3392 | 2 | |
| 3393 | Occurrence Span Code DT (From) | |
| 3394 | 8 N | |
| 3395 | CCYYMMDD | |
| 3396 | 837: (I) 2 300 HI01 - 4 | |
| 3397 | Print: | |
| 3398 | UB04 – FL3 5-36 | |
| 3399 | Biller Inp ut: Screen 4/5 Secti on 6/7 | |
| 3400 | Storage: | |
| 3401 | File: BILL /CLAIMS (# 399) | |
| 3402 | Subfile: O CCURRENCE CODE (#41) | |
| 3403 | Field: DAT E (#.02) | |
| 3404 | Set HI03 = RD8. | |
| 3405 | 3 | |
| 3406 | Occurrence Span Code DT (Throu gh) | |
| 3407 | 8 N | |
| 3408 | CCYYMMDD | |
| 3409 | 837: (I) 2 300 HI01 – 4 | |
| 3410 | Print: | |
| 3411 | UB04 – FL3 5-36 | |
| 3412 | Biller Inp ut: Screen 4/5 Secti on 6/7 | |
| 3413 | Storage: | |
| 3414 | File: BILL /CLAIMS (# 399) | |
| 3415 | Subfile: O CCURRENCE CODE (#41) | |
| 3416 | Field: END DATE (#.0 4) | |
| 3417 | ||
| 3418 | 4 | |
| 3419 | Occurrence Span Code | |
| 3420 | 3 A/N | |
| 3421 | 837: (I) 2 300 HI01 - 2 | |
| 3422 | Print: | |
| 3423 | UB04 – FL3 5-36 | |
| 3424 | Biller Inp ut: Screen 4/5 Secti on 6/7 | |
| 3425 | Storage: | |
| 3426 | File: BILL /CLAIMS (# 399) | |
| 3427 | Subfile: O CCURRENCE CODE (#41) | |
| 3428 | Field: OCC URRENCE CO DE (#.01) | |
| 3429 | Set HI02 = BI | |
| 3430 | ||
| 3431 | PC1-PC12 - Loop 2300 (Procedur e Code Dat a) [SEQ 75 ] | |
| 3432 | Inpatient Only - one or more r ecords per Claim Dat a record - may repea t 1-25 (1 Principal and 24 Oth er) | |
| 3433 | (OPTIONAL – Max len gth 28 byt es) | |
| 3434 | Piece | |
| 3435 | Descriptio n | |
| 3436 | Max Length | |
| 3437 | Data Type | |
| 3438 | 837/Print Location | |
| 3439 | VistA Inpu t/Storage | |
| 3440 | ||
| 3441 | FSC Proces sing Comme nts | |
| 3442 | 1 | |
| 3443 | RECORD ID = ‘PC1 ’ - ‘PC12’ | |
| 3444 | 4 A | |
| 3445 | ||
| 3446 | ||
| 3447 | ||
| 3448 | 2 | |
| 3449 | Procedure DT | |
| 3450 | ||
| 3451 | 8 N | |
| 3452 | CCYYMMDD | |
| 3453 | 837: (I) 2 300 HI01 - 4 | |
| 3454 | Print: | |
| 3455 | UB04 – FL7 4, 74a-e | |
| 3456 | Biller Inp ut: Screen 4 Section 4 | |
| 3457 | Storage: | |
| 3458 | File: BILL /CLAIMS (# 399) | |
| 3459 | Subfile: P ROCEDURES (#304) | |
| 3460 | Field: PRO CEDURE DAT ES (#1) | |
| 3461 | Set HI01-3 = D8 | |
| 3462 | 3 | |
| 3463 | Procedure Code | |
| 3464 | 10 A/N | |
| 3465 | 837: (I) 2 300 HI01 - 2 | |
| 3466 | Print: | |
| 3467 | UB04 – FL7 4, 741-e | |
| 3468 | Biller Inp ut: Screen 4 Section 4 | |
| 3469 | Storage: | |
| 3470 | File: BILL /CLAIMS (# 399) | |
| 3471 | Subfile: P ROCEDURES (#304) | |
| 3472 | Field: PRO CEDURE DAT ES (#1) | |
| 3473 | ||
| 3474 | 4 | |
| 3475 | Procedure Code Quali fier | |
| 3476 | 3 A | |
| 3477 | 837: (I) 2 300 HI01 – 1 | |
| 3478 | Print: N/A | |
| 3479 | Biller Inp ut: N/A | |
| 3480 | Whether a procedure is the Pri ncipal (BR or BBR) o r Other (B Q or BBQ) is determi ned by the order in which they are added to the cl aim. | |
| 3481 | Storage: N /A | |
| 3482 | Note: Alwa ys BR or B Q for ICD 9 | |
| 3483 | Always BBR or BBQ fo r ICD 10 | |
| 3484 | ||
| 3485 | ||
| 3486 | ||
| 3487 | SPC- Loop 2300 (Surg ical Proce dure Code Data) [SE Q 77] | |
| 3488 | (OPTIONAL – Max len gth 34 byt es) | |
| 3489 | Piece | |
| 3490 | Descriptio n | |
| 3491 | Max Length | |
| 3492 | Data Type | |
| 3493 | 837/Print Location | |
| 3494 | VistA Inpu t/Storage | |
| 3495 | FSC Proces sing Comme nts | |
| 3496 | 1 | |
| 3497 | RECORD ID = SPC | |
| 3498 | 4 A | |
| 3499 | ||
| 3500 | ||
| 3501 | ||
| 3502 | 2 | |
| 3503 | Primary Su rgical Pro cedure Cod e Qualifie r | |
| 3504 | 3 A | |
| 3505 | 837: (P) 2 300 HI01 – 1 | |
| 3506 | Print: N/A | |
| 3507 | Biller Inp ut: N/A | |
| 3508 | Storage: N /A | |
| 3509 | Note: Alwa ys BP | |
| 3510 | ||
| 3511 | 3 | |
| 3512 | Primary Su rgical Pro cedure Cod e | |
| 3513 | 10 A/N | |
| 3514 | 837: (P) 2 300 HI01 – 2 | |
| 3515 | Print: N/A | |
| 3516 | Biller Inp ut: Screen 8 Section 3 | |
| 3517 | Storage: | |
| 3518 | File: BILL /CLAIMS (# 399) | |
| 3519 | Field: PRI MARY SURGI CAL PROC C ODE (#266) | |
| 3520 | ||
| 3521 | 4 | |
| 3522 | Secondary Surgical P rocedure C ode Qualif ier | |
| 3523 | 3 A | |
| 3524 | 837: (P) 2 300 H201 – 1 | |
| 3525 | Print: N/A | |
| 3526 | Biller Inp ut: N/A | |
| 3527 | Storage: N /A | |
| 3528 | Note: Alwa ys BO | |
| 3529 | ||
| 3530 | ||
| 3531 | 5 | |
| 3532 | Secondary Surgical P rocedure C ode | |
| 3533 | 10 A/N | |
| 3534 | 837: (P) 2 300 H201 – 2 | |
| 3535 | Print: N/A | |
| 3536 | Biller Inp ut: Screen 8 Section 3 | |
| 3537 | Storage: | |
| 3538 | File: BILL /CLAIMS (# 399) | |
| 3539 | Field: SEC ONDARY SUR GICAL PROC CODE (#26 7) | |
| 3540 | ||
| 3541 | ||
| 3542 | VC1-VC12 - Loop 2300 (Value Co de Data) [ SEQ 80] | |
| 3543 | Inpatient Only - one or more r ecords per Claim Dat a record s et - may r epeat 1-12 | |
| 3544 | (OPTIONAL – Max len gth 18 byt es) | |
| 3545 | Piece | |
| 3546 | Descriptio n | |
| 3547 | Max Length Data Type | |
| 3548 | 837/Print Location | |
| 3549 | VistA Inpu t/Storage | |
| 3550 | FSC Proces sing Comme nts | |
| 3551 | 1 | |
| 3552 | RECORD ID = ‘VC1 ’ - ‘VC12’ | |
| 3553 | 4 A | |
| 3554 | ||
| 3555 | ||
| 3556 | ||
| 3557 | 2 | |
| 3558 | VALUE CODE | |
| 3559 | ||
| 3560 | 3 A/N | |
| 3561 | 837: (I) 2 300 HI01 - 2 | |
| 3562 | Print: | |
| 3563 | UB04 – FL3 9-41a-d Se ction 1 | |
| 3564 | Biller Inp ut: Screen 4 Section 8 | |
| 3565 | Storage: | |
| 3566 | File: BILL /CLAIMS (# 399) | |
| 3567 | Subfile: V ALUE CODE (#47) | |
| 3568 | Field: VAL UE CODE (# .01) | |
| 3569 | Set HI101 -1 = BE. | |
| 3570 | 3 | |
| 3571 | Value Code Associate d Amt | |
| 3572 | 9 N | |
| 3573 | 2 Decimals | |
| 3574 | 837: (I) 2 300 HI01 - 5 | |
| 3575 | Print: | |
| 3576 | UB04 – FL3 9-41a-d Se ction 2 | |
| 3577 | Biller Inp ut: Screen 4 Section 8 | |
| 3578 | Storage: | |
| 3579 | File: BILL /CLAIMS (# 399) | |
| 3580 | Subfile: V ALUE CODE (#47) | |
| 3581 | Field: VAL UE (#.02) | |
| 3582 | ||
| 3583 | CC1-CC12 - Loop 2300 (Conditio n Code Dat a) [SEQ 85 ] | |
| 3584 | (OPTIONAL – Max len gth 7 byte s) | |
| 3585 | Piece | |
| 3586 | Descriptio n | |
| 3587 | Max Length Data Type | |
| 3588 | 837/Print Location | |
| 3589 | VistA Inpu t/Storage | |
| 3590 | FSC Proces sing Comme nts | |
| 3591 | 1 | |
| 3592 | RECORD ID = ‘CC1 ’ - ‘CC12’ | |
| 3593 | 4 A | |
| 3594 | ||
| 3595 | ||
| 3596 | ||
| 3597 | 2 | |
| 3598 | CONDITION CODE | |
| 3599 | 2 A/N | |
| 3600 | 837: | |
| 3601 | (I) 2300 H I01- 2 | |
| 3602 | (P) 2300 H I01- 2 | |
| 3603 | Print: | |
| 3604 | UB04 – FL 18-28 | |
| 3605 | Biller Inp ut: Screen 4/5 Secti on 7/8 | |
| 3606 | Storage: | |
| 3607 | File: BILL /CLAIMS (# 399) | |
| 3608 | Subfile: C ONDITION C ODE (#40) | |
| 3609 | Field: CON DITION COD E (#.01) | |
| 3610 | Set HI01-1 to BG. | |
| 3611 | ||
| 3612 | ||
| 3613 | DC1-DC12 - Loop 2300 (Diagnosi s Code Dat a) [SEQ 90 ] | |
| 3614 | One or mor e records per Claim Data recor d set | |
| 3615 | UB-04 clai ms can hav e 1 princi ple DX, 24 other DXs , and 12 E xternal Ca use of Inj ury DXs. | |
| 3616 | CMS-1500 c laims can have 12 DX s. | |
| 3617 | (OPTIONAL – Max len gth 21 byt es) | |
| 3618 | Piece | |
| 3619 | Descriptio n | |
| 3620 | Max Length Data Type | |
| 3621 | 837/Print Location | |
| 3622 | VistA Inpu t/Storage | |
| 3623 | FSC Proces sing Comme nts | |
| 3624 | 1 | |
| 3625 | RECORD ID = ‘DC1 ’ - ‘DC12’ | |
| 3626 | 4 A | |
| 3627 | ||
| 3628 | ||
| 3629 | ||
| 3630 | 2 | |
| 3631 | DIAGNOSIS CODE | |
| 3632 | ||
| 3633 | 10 A/N | |
| 3634 | 837: | |
| 3635 | 2300 HI01 – 2 | |
| 3636 | (I) 2300 H I03 – 2 | |
| 3637 | Print: | |
| 3638 | CMS 1500 – Box 21A-L | |
| 3639 | UB04 – FL 67, 67A-Q | |
| 3640 | UB04 – FL 72a-c | |
| 3641 | Biller Inp ut: Screen 4/5 Secti on 3/2 | |
| 3642 | Users may add diagno ses to a c laim from Screen 4/5 . The ord er of the diagnoses determines default v alue for A dmission D x. | |
| 3643 | Storage: | |
| 3644 | File: IB B ILL/CLAIMS DIAGNOSIS (#362.3) | |
| 3645 | Field: DIA GNOSIS (#. 01) | |
| 3646 | ||
| 3647 | 3 | |
| 3648 | Code List Qualifier Code | |
| 3649 | 3 A/N | |
| 3650 | 837: | |
| 3651 | 2300 HI01 – 1 (BK, B F) | |
| 3652 | (I) 2300 H I03 – 1 (B N) | |
| 3653 | Print: N/A | |
| 3654 | Biller Inp ut: N/A | |
| 3655 | Users may add diagno ses to a c laim from Screen 4/5 . The qua lifiers wi ll be auto matically assigned b ased on or der and wh ether the code is an E-code. | |
| 3656 | Storage: N /A | |
| 3657 | May be BK, BF or BN for ICD -9 | |
| 3658 | May be ABK , ABF, and ABN for I CD-10 | |
| 3659 | 4 | |
| 3660 | Present on Admission Indicator | |
| 3661 | 1 A/N | |
| 3662 | 837: | |
| 3663 | (I) 2300 H I01-9 | |
| 3664 | Print: | |
| 3665 | UB04 – FL6 7A-Q | |
| 3666 | UB04 – FL 72a-c | |
| 3667 | Biller Inp ut: Screen 4 Section 3 | |
| 3668 | Users ente r the POA indicator for inpati ent claims . | |
| 3669 | Storage: | |
| 3670 | File: IB B ILL/CLAIMS DIAGNOSIS (#362.3) | |
| 3671 | Field: POA INDICATOR (#.04) | |
| 3672 | None | |
| 3673 | ||
| 3674 | OPR - Loop 2310A/B/C (Att/Othe r Oper/Ope r Physicia n/Provider Data) [SE Q 96] | |
| 3675 | One record per Claim Data reco rd set | |
| 3676 | (OPTIONAL – Max len gth 234 by tes) | |
| 3677 | Piece | |
| 3678 | Descriptio n | |
| 3679 | Max Length Data Type | |
| 3680 | 837/Print Location | |
| 3681 | VistA Inpu t/Storage | |
| 3682 | FSC Proces sing Comme nts | |
| 3683 | 1 | |
| 3684 | RECORD ID = ‘OPR ’ | |
| 3685 | 4 A | |
| 3686 | ||
| 3687 | ||
| 3688 | ||
| 3689 | 2 | |
| 3690 | Attending Prov Last Name | |
| 3691 | 20 A/N | |
| 3692 | 837: (I) 2 310A NM103 | |
| 3693 | Print: | |
| 3694 | CMS 1500 – Box 31 as signature | |
| 3695 | UB04 – FL7 6 | |
| 3696 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3697 | Storage: | |
| 3698 | File: BILL /CLAIMS (# 399) | |
| 3699 | Subfile: P ROVIDER (# 222) | |
| 3700 | Field: PER FORMED BY (#.02) | |
| 3701 | Maximum HI PAA length increased to 60. | |
| 3702 | (I)Set NM 101 = 71 N M102 = 1 | |
| 3703 | 837P moved to OPR9 r ecord | |
| 3704 | 3 | |
| 3705 | Attending Prov First Name | |
| 3706 | 20 A/N | |
| 3707 | 837: (I) 2 310A NM104 | |
| 3708 | Print: | |
| 3709 | CMS 1500 – Box 31 as signature | |
| 3710 | UB04 – FL7 6 | |
| 3711 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3712 | Storage: | |
| 3713 | File: BILL /CLAIMS (# 399) | |
| 3714 | Subfile: P ROVIDER (# 222) | |
| 3715 | Field: PER FORMED BY (#.02) | |
| 3716 | Maximum HI PAA length increased to 35. | |
| 3717 | 837P moved to OPR9 r ecord | |
| 3718 | 4 | |
| 3719 | Attending Prov Name Suffix | |
| 3720 | 10 A/N | |
| 3721 | 837: (I) 2 310A NM107 | |
| 3722 | Print: | |
| 3723 | CMS 1500 – Box 31 as signature | |
| 3724 | UB04 – FL7 6 | |
| 3725 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3726 | Storage: | |
| 3727 | File: BILL /CLAIMS (# 399) | |
| 3728 | Subfile: P ROVIDER (# 222) | |
| 3729 | Field: PER FORMED BY (#.02) | |
| 3730 | ||
| 3731 | 837P moved to OPR9 r ecord | |
| 3732 | 5 | |
| 3733 | BLANK | |
| 3734 | 1 | |
| 3735 | ||
| 3736 | ||
| 3737 | Moved to O PR piece 1 7 | |
| 3738 | 6 | |
| 3739 | Other Oper ating Prov Last Name | |
| 3740 | ||
| 3741 | 20 A/N | |
| 3742 | 837: (I) 2 310C NM103 | |
| 3743 | Print: | |
| 3744 | UB04 – FL7 8-79 | |
| 3745 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3746 | Storage: | |
| 3747 | File: BILL /CLAIMS (# 399) | |
| 3748 | Subfile: P ROVIDER (# 222) | |
| 3749 | Field: PER FORMED BY (#.02) | |
| 3750 | Set NM101 = ZZ | |
| 3751 | NM102 = 1 | |
| 3752 | 7 | |
| 3753 | Other Oper ating Prov First Nam e | |
| 3754 | ||
| 3755 | 20 A/N | |
| 3756 | 837: (I) 2 310C NM104 | |
| 3757 | Print: | |
| 3758 | UB04 – FL7 8-79 | |
| 3759 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3760 | Storage: | |
| 3761 | File: BILL /CLAIMS (# 399) | |
| 3762 | Subfile: P ROVIDER (# 222) | |
| 3763 | Field: PER FORMED BY (#.02) | |
| 3764 | ||
| 3765 | 8 | |
| 3766 | Other Oper ating Prov Name Suff ix | |
| 3767 | 10 A/N | |
| 3768 | 837: (I) 2 310C NM107 | |
| 3769 | Print: | |
| 3770 | UB04 – FL7 8-79 | |
| 3771 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3772 | Storage: | |
| 3773 | File: BILL /CLAIMS (# 399) | |
| 3774 | Subfile: P ROVIDER (# 222) | |
| 3775 | Field: PER FORMED BY (#.02) | |
| 3776 | ||
| 3777 | 9 | |
| 3778 | Operating Phy Last N ame | |
| 3779 | 20 A/N | |
| 3780 | 837: (I) 2 310B NM103 | |
| 3781 | Print: | |
| 3782 | UB04 – FL7 7 | |
| 3783 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3784 | Storage: | |
| 3785 | File: BILL /CLAIMS (# 399) | |
| 3786 | Subfile: P ROVIDER (# 222) | |
| 3787 | Field: PER FORMED BY (#.02) | |
| 3788 | Set NM101 = 72 | |
| 3789 | NM102 = 1 | |
| 3790 | 10 | |
| 3791 | Operating Phy First Name | |
| 3792 | 20 A/N | |
| 3793 | 837: (I) 2 310B NM104 | |
| 3794 | Print: | |
| 3795 | UB04 – FL7 7 | |
| 3796 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3797 | Storage: | |
| 3798 | File: BILL /CLAIMS (# 399) | |
| 3799 | Subfile: P ROVIDER (# 222) | |
| 3800 | Field: PER FORMED BY (#.02) | |
| 3801 | Maximum HI PAA length increased to 35. | |
| 3802 | 11 | |
| 3803 | Operating Phy Name S uffix | |
| 3804 | 10 A/N | |
| 3805 | 837: (I) 2 310B NM107 | |
| 3806 | Print: | |
| 3807 | UB04 – FL7 7 | |
| 3808 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3809 | Storage: | |
| 3810 | File: BILL /CLAIMS (# 399) | |
| 3811 | Subfile: P ROVIDER (# 222) | |
| 3812 | Field: PER FORMED BY (#.02) | |
| 3813 | ||
| 3814 | 12 | |
| 3815 | BLANK | |
| 3816 | 1 | |
| 3817 | ||
| 3818 | ||
| 3819 | ||
| 3820 | 13 | |
| 3821 | Referring Prov Last Name | |
| 3822 | 20 A/N | |
| 3823 | 837: | |
| 3824 | (P) 2310A NM103 | |
| 3825 | (I) 2310F NM103 | |
| 3826 | Print: | |
| 3827 | CMS 1500 – Box 17 | |
| 3828 | UB04 – FL7 8-79 | |
| 3829 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3830 | Storage: | |
| 3831 | File: BILL /CLAIMS (# 399) | |
| 3832 | Subfile: P ROVIDER (# 222) | |
| 3833 | Field: PER FORMED BY (#.02) | |
| 3834 | Maximum HI PAA length is 60. | |
| 3835 | Set NM101 = DN | |
| 3836 | NM102 = 1 | |
| 3837 | 14 | |
| 3838 | Referring Prov First Name | |
| 3839 | 20 A/N | |
| 3840 | 837: | |
| 3841 | (P) 2310A NM104 | |
| 3842 | (I) 2310F NM104 | |
| 3843 | Print: | |
| 3844 | CMS 1500 – Box 17 | |
| 3845 | UB04 – FL7 8-79 | |
| 3846 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3847 | Storage: | |
| 3848 | File: BILL /CLAIMS (# 399) | |
| 3849 | Subfile: P ROVIDER (# 222) | |
| 3850 | Field: PER FORMED BY (#.02) | |
| 3851 | Maximum HI PAA length is 35. | |
| 3852 | ||
| 3853 | 15 | |
| 3854 | Referring Prov Name Suffix | |
| 3855 | 10 A/N | |
| 3856 | 837: | |
| 3857 | (P) 2310A NM107 | |
| 3858 | (I) 2310F NM107 | |
| 3859 | Print: | |
| 3860 | CMS 1500 – Box 17 | |
| 3861 | UB04 – FL7 8-79 | |
| 3862 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3863 | Storage: | |
| 3864 | File: BILL /CLAIMS (# 399) | |
| 3865 | Subfile: P ROVIDER (# 222) | |
| 3866 | Field: PER FORMED BY (#.02) | |
| 3867 | ||
| 3868 | 16 | |
| 3869 | Attending Prov Taxon omy Qualif ier | |
| 3870 | 2 A/N | |
| 3871 | 837: (I)23 10A PRV01 | |
| 3872 | Print: N/A | |
| 3873 | Biller Inp ut: N/A | |
| 3874 | Storage: N /A | |
| 3875 | Note: Alwa ys AT | |
| 3876 | 837P moved to OPR9 r ecord | |
| 3877 | 17 | |
| 3878 | Attending Prov Taxon omy | |
| 3879 | 10 A/N | |
| 3880 | 837: (I)23 10A PRV03 | |
| 3881 | Print: N/A | |
| 3882 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3883 | The physic ian’s taxo nomy code is default ed from th e New Pers onPerson C lass file but may be overridde n by the b iller. | |
| 3884 | Storage: | |
| 3885 | File: BILL /CLAIMS (# 399) | |
| 3886 | Subfile: P ROVIDER (# 222) | |
| 3887 | Field: TAX ONOMY (#.1 5) | |
| 3888 | Set PRV02 = PXC. | |
| 3889 | 837P moved to OPR9 r ecord | |
| 3890 | OPR1 - Loo p 2310A/B (Att/Other Oper/Oper Physician /Provider Data) [SEQ 97] | |
| 3891 | One record per Claim Data reco rd | |
| 3892 | (OPTIONAL – Max len gth 74 byt es) | |
| 3893 | Piece | |
| 3894 | Descriptio n | |
| 3895 | Max Length Data Type | |
| 3896 | 837/Print Location | |
| 3897 | VistA Inpu t/Storage | |
| 3898 | FSC Proces sing Comme nts | |
| 3899 | 1 | |
| 3900 | RECORD ID = ‘OPR1’ | |
| 3901 | 4 A | |
| 3902 | ||
| 3903 | ||
| 3904 | ||
| 3905 | 2 | |
| 3906 | Attending Prov Prima ry ID Qual ifier | |
| 3907 | 2 A/N | |
| 3908 | 837: (I) 2 310A NM108 | |
| 3909 | Print: N/A | |
| 3910 | Biller Inp ut: N/A | |
| 3911 | Storage: N /A | |
| 3912 | Note: Alwa ys XX | |
| 3913 | 837P moved to OPR9 r ecord | |
| 3914 | 3 | |
| 3915 | Attending Prov Prima ry ID | |
| 3916 | 10 A/N | |
| 3917 | 837: (I) 2 310A NM109 | |
| 3918 | Print: | |
| 3919 | UB04 – FL7 6 | |
| 3920 | Biller Inp ut: N/A | |
| 3921 | The biller can add a provider to a claim but the p rovider’s NPI comes from the N ew Person file. | |
| 3922 | Storage: | |
| 3923 | File: NEW PERSON (#2 00) | |
| 3924 | Field: NPI (#41.99) | |
| 3925 | 837P moved to OPR9 r ecord | |
| 3926 | 4 | |
| 3927 | Attending Prov Entit y Type Qua lifier | |
| 3928 | 1 A/N | |
| 3929 | 837: | |
| 3930 | (I) 2310A NM102 | |
| 3931 | (P) 2310B NM102 | |
| 3932 | Print: N/A | |
| 3933 | Biller Inp ut: N/A | |
| 3934 | Storage: N /A | |
| 3935 | 837I Code 2 deleted only 1 = P erson allo wed | |
| 3936 | 5 | |
| 3937 | Other Oper ating Prov Primary I D Qualifie r | |
| 3938 | 2 A/N | |
| 3939 | 837: (I) 2 310C NM108 | |
| 3940 | Print: N/A | |
| 3941 | Biller Inp ut: N/A | |
| 3942 | Storage: N /A | |
| 3943 | Note: Alwa ys XX | |
| 3944 | Name chang ed from Ot her Provid er to Othe r Operatin g Provider s. | |
| 3945 | Usage only allowed w hen an Ope rating Pro vider is s pecified i n 2310B. | |
| 3946 | 6 | |
| 3947 | Other Oper ating Prov ider Prima ry ID | |
| 3948 | 10 A/N | |
| 3949 | 837: (I) 2 310C NM109 | |
| 3950 | Print: | |
| 3951 | UB04 – FL7 8 | |
| 3952 | Biller Inp ut: N/A | |
| 3953 | The biller can add a provider to a claim but the p rovider’s NPI comes from the N ew Person file. | |
| 3954 | Storage: | |
| 3955 | File: NEW PERSON (#2 00) | |
| 3956 | Field: NPI (#41.99) | |
| 3957 | Name chang ed from Ot her Provid er to Othe r Operatin g Provider s. | |
| 3958 | Usage only allowed w hen an Ope rating Pro vider is s pecified i n 2310B. | |
| 3959 | 7 | |
| 3960 | Other Oper ating Prov Entity Ty pe Qualifi er | |
| 3961 | 1 A/N | |
| 3962 | 837: (I) 2 310C NM102 | |
| 3963 | Print: N/A | |
| 3964 | Biller Inp ut: N/A | |
| 3965 | Storage: N /A | |
| 3966 | Usage only allowed w hen an Ope rating Pro vider is s pecified i n 2310B. 8 37I Code 2 deleted o nly 1 = Pe rson allow ed. Usage changed to situation al. | |
| 3967 | 8 | |
| 3968 | Operating Phy Primar y ID Quali fier | |
| 3969 | 2 A/N | |
| 3970 | 837: (I) 2 310B NM108 | |
| 3971 | Print: N/A | |
| 3972 | Biller Inp ut: N/A | |
| 3973 | Storage: N /A | |
| 3974 | Note: Alwa ys XX | |
| 3975 | ||
| 3976 | 9 | |
| 3977 | Operating Phy Primar y ID | |
| 3978 | 10 A/N | |
| 3979 | 837: (I) 2 310B NM109 | |
| 3980 | Print: | |
| 3981 | UB04 – FL7 7 | |
| 3982 | Biller Inp ut: N/A | |
| 3983 | The biller can add a provider to a claim but the p rovider’s NPI comes from the N ew Person file. | |
| 3984 | Storage: | |
| 3985 | File: NEW PERSON (#2 00) | |
| 3986 | Field: NPI (#41.99) | |
| 3987 | ||
| 3988 | 10 | |
| 3989 | Rend Prov Credential s | |
| 3990 | ||
| 3991 | 3 A/N | |
| 3992 | 837: (P) 2 310B NM106 | |
| 3993 | Print: | |
| 3994 | CMS 1500 – Box 31 | |
| 3995 | ||
| 3996 | Note: Used for print ing if HCC H needs to drop the claim to p rint. | |
| 3997 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 3998 | The biller can add a provider to a claim but the p rovider’s credential s come fro m the New Person fil eProvider Class. Th e biller c an overrid e the defa ult creden tials. | |
| 3999 | Storage: | |
| 4000 | File: BILL /CLAIM (#3 99) | |
| 4001 | Subfile: P ROVIDER (# 222) | |
| 4002 | Field: CRE DENTIALS ( #.03) | |
| 4003 | Not a HIPA A data ele ment. | |
| 4004 | HCCH print ing requir ements. | |
| 4005 | 11 | |
| 4006 | Referring Prov Prima ry ID Qual ifier | |
| 4007 | 2 A/N | |
| 4008 | 837: | |
| 4009 | (P)2310A N M108 | |
| 4010 | (I)2310F N M108 | |
| 4011 | Print: N/A | |
| 4012 | Biller Inp ut: N/A | |
| 4013 | Storage: N /A | |
| 4014 | Note: Alwa ys XX | |
| 4015 | ||
| 4016 | 12 | |
| 4017 | Referring Provider P rimary ID | |
| 4018 | 10 A/N | |
| 4019 | 837: | |
| 4020 | (P) 2310A NM109 | |
| 4021 | (I) 2310F NM109 | |
| 4022 | Print: | |
| 4023 | CMS 1500 – Box 17b | |
| 4024 | UB04 – FL7 8 - 79 | |
| 4025 | Biller Inp ut: N/A | |
| 4026 | The biller can add a provider to a claim but the p rovider’s NPI comes from the N ew Person file. | |
| 4027 | Storage: | |
| 4028 | File: NEW PERSON (#2 00) | |
| 4029 | Field: NPI (#41.99) | |
| 4030 | ||
| 4031 | 13 | |
| 4032 | BLANK | |
| 4033 | 1 | |
| 4034 | ||
| 4035 | ||
| 4036 | ||
| 4037 | 14 | |
| 4038 | Referring Prov Entit y Type Qua lifier | |
| 4039 | 1 A/N | |
| 4040 | 837: | |
| 4041 | (P) 2310A NM102 | |
| 4042 | (I)2310F N M102 | |
| 4043 | Print: N/A | |
| 4044 | Biller Inp ut: N/A | |
| 4045 | Storage: N /A | |
| 4046 | None | |
| 4047 | 15 | |
| 4048 | Operating Phy Entity Type Qual ifier | |
| 4049 | 1 A/N | |
| 4050 | 837: (I) 2 310B NM102 | |
| 4051 | Print: N/A | |
| 4052 | Biller Inp ut: N/A | |
| 4053 | Storage: N /A | |
| 4054 | 837I Code 2 deleted only 1 = Person all owed. | |
| 4055 | ||
| 4056 | OPR2 - Loo p 2310A (A ttending P rovider Se condary ID Data) [SE Q 98] | |
| 4057 | One record per Claim Data reco rd | |
| 4058 | (OPTIONAL – Max len gth 140 by tes) | |
| 4059 | Piece | |
| 4060 | Descriptio n | |
| 4061 | Max Length Data Type | |
| 4062 | 837/Print Location | |
| 4063 | VistA Inpu t/Storage | |
| 4064 | FSC Proces sing Comme nts | |
| 4065 | 1 | |
| 4066 | RECORD ID = ‘OPR2 ’ | |
| 4067 | 4 A | |
| 4068 | ||
| 4069 | ||
| 4070 | ||
| 4071 | 2 | |
| 4072 | Attending Prov Seco ndary ID Q ualifier ( 1) | |
| 4073 | 2 A/N | |
| 4074 | 837: (I) 2 310A REF01 | |
| 4075 | Print: | |
| 4076 | UB04 – FL7 6 | |
| 4077 | Note: G2 o r 1G ID us ed if no I D provided by the In surance Co mpany is f ound | |
| 4078 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4079 | When a use r adds a p rovider to a claim, they will be given a n opportun ity to ent er one sec ondary ID. The seco ndary IDs are define d in Provi der ID Mai ntenance. An ID can belong to the provi der or it can be ass igned to t he provide r by the p ayer. | |
| 4080 | VistA will extract u p to the m aximum num ber of pro vider seco ndary IDs into the 8 37. | |
| 4081 | Storage: | |
| 4082 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4083 | Field: PRO VIDER ID T YPE (#.06) | |
| 4084 | Code Set C hange: | |
| 4085 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4086 | ||
| 4087 | Profession al renderi ng informa tion move to OPRA | |
| 4088 | 3 | |
| 4089 | Attending Prov Seco ndary ID ( 1) | |
| 4090 | 30 A/N | |
| 4091 | 837: (I) 2 310A REF01 | |
| 4092 | Print: | |
| 4093 | UB04 – FL7 6 | |
| 4094 | Note: The software l ooks for t he first c ompliant s econdary I D to print . Only one Secondary ID prints in FL78. | |
| 4095 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4096 | When a use r adds a p rovider to a claim, they will be given a n opportun ity to ent er one sec ondary ID. The seco ndary IDs are define d in Provi der ID Mai ntenance. An ID can belong to the provi der or it can be ass igned to t he provide r by the p ayer. | |
| 4097 | VistA will extract u p to the m aximum num ber of pro vider seco ndary IDs into the 8 37. | |
| 4098 | Storage: | |
| 4099 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4100 | Field: PRO VIDER ID ( #.07) | |
| 4101 | Profession al renderi ng informa tion move to OPRA | |
| 4102 | 4 | |
| 4103 | Attending Prov Sec ID Qualifi er (2) | |
| 4104 | 2 A/N | |
| 4105 | 837: (I) 2 310A REF01 | |
| 4106 | Print: N/A | |
| 4107 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4108 | Billers ad d the prov ider to th e claim. | |
| 4109 | Storage: | |
| 4110 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4111 | Field: PRO VIDER ID T YPE (#.06) | |
| 4112 | Code Set C hange: | |
| 4113 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4114 | Profession al renderi ng informa tion move to OPRA | |
| 4115 | 5 | |
| 4116 | Attending Prov Sec ID (2) | |
| 4117 | 30 A/N | |
| 4118 | 837: (I) 2 310A REF02 | |
| 4119 | Print: N/A | |
| 4120 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4121 | Billers ad d the prov ider to th e claim. | |
| 4122 | Storage: | |
| 4123 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4124 | Field: PRO VIDER ID ( #.07) | |
| 4125 | Profession al renderi ng informa tion move to OPRA | |
| 4126 | 6 | |
| 4127 | Attending Prov Sec ID Qualifi er (3) | |
| 4128 | 2 A/N | |
| 4129 | 837: (I) 2 310A REF01 | |
| 4130 | Print: N/A | |
| 4131 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4132 | Billers ad d the prov ider to th e claim. | |
| 4133 | Storage: | |
| 4134 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4135 | Field: PRO VIDER ID T YPE (#.06) | |
| 4136 | Code Set C hange: | |
| 4137 | Only codes now allow ed are 0B, 1G, G2 an d LU | |
| 4138 | Profession al renderi ng informa tion move to OPRA. | |
| 4139 | 7 | |
| 4140 | Attending Prov Sec ID (3) | |
| 4141 | 30 A/N | |
| 4142 | 837: (I) 2 310A REF02 | |
| 4143 | Print: N/A | |
| 4144 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4145 | Billers ad d the prov ider to th e claim. | |
| 4146 | Storage: | |
| 4147 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4148 | Field: PRO VIDER ID ( #.07) | |
| 4149 | Profession al renderi ng informa tion move to OPRA | |
| 4150 | 8 | |
| 4151 | Attending Prov Sec ID Qualifi er (4) | |
| 4152 | 2 A/N | |
| 4153 | 837: (I) 2 310A REF01 | |
| 4154 | Print: N/A | |
| 4155 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4156 | Billers ad d the prov ider to th e claim. | |
| 4157 | Storage: | |
| 4158 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4159 | Field: PRO VIDER ID T YPE (#.06) | |
| 4160 | Code Set C hange: | |
| 4161 | Only codes now allow ed are 0B, 1G, G2 an d LU | |
| 4162 | Profession al renderi ng informa tion move to OPRA | |
| 4163 | 9 | |
| 4164 | Attending Prov Sec ID (4) | |
| 4165 | 30 A/N | |
| 4166 | 837: | |
| 4167 | (I) 2310A REF02 | |
| 4168 | (P) 2310B REF02 | |
| 4169 | Print: N/A | |
| 4170 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4171 | Billers ad d the prov ider to th e claim. | |
| 4172 | Storage: | |
| 4173 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4174 | Field: PRO VIDER ID ( #.07) | |
| 4175 | Profession al Renderi ng informa tion move to OPRA | |
| 4176 | ||
| 4177 | ||
| 4178 | OPR3 - Loo p 2310B (O perating P hysician S econdary I D Data) [S EQ 99] | |
| 4179 | One record per Claim Data reco rd | |
| 4180 | (Optional – Max len gth 141 by tes) | |
| 4181 | Piece | |
| 4182 | Descriptio n | |
| 4183 | Max Length Data Type | |
| 4184 | 835/Print Location | |
| 4185 | VistA Inpu t/Storage | |
| 4186 | FSC Proces sing Comme nts | |
| 4187 | 1 | |
| 4188 | RECORD ID = ‘OPR3 ’ | |
| 4189 | 4 A | |
| 4190 | ||
| 4191 | ||
| 4192 | ||
| 4193 | 2 | |
| 4194 | Operating Phy Sec ID Qualifier (1) | |
| 4195 | ||
| 4196 | 2 A/N | |
| 4197 | 837: (I) 2 310B REF01 | |
| 4198 | Print: | |
| 4199 | UB04 – FL7 7 | |
| 4200 | Note: G2 o r 1G ID us ed if no I D provided by the In surance Co mpany is f ound | |
| 4201 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4202 | Billers ad d the prov ider to th e claim. | |
| 4203 | Storage: | |
| 4204 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4205 | Field: PRO VIDER ID T YPE (#.06) | |
| 4206 | Code Set C hange: | |
| 4207 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4208 | 3 | |
| 4209 | Operating Phy Sec ID (1) | |
| 4210 | 30 A/N | |
| 4211 | 837: (I) 2 310B REF02 | |
| 4212 | Print: | |
| 4213 | UB04 – FL7 7 | |
| 4214 | ||
| 4215 | Note: The software l ooks for t he first c ompliant s econdary I D to print . Only one Secondary ID prints in FL78. | |
| 4216 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4217 | When a use r adds a p rovider to a claim, they will be given a n opportun ity to ent er one sec ondary ID. The seco ndary IDs are define d in Provi der ID Mai ntenance. An ID can belong to the provi der or it can be ass igned to t he provide r by the p ayer. | |
| 4218 | VistA will extract u p to the m aximum num ber of pro vider seco ndary IDs into the 8 37. | |
| 4219 | Storage: | |
| 4220 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4221 | Field: PRO VIDER ID ( #.07) | |
| 4222 | ||
| 4223 | 4 | |
| 4224 | Operating Phy Sec ID Qualifier (2) | |
| 4225 | 2 A/N | |
| 4226 | 837: (I) 2 310B REF01 | |
| 4227 | Print: N/A | |
| 4228 | ||
| 4229 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4230 | Billers ad d the prov ider to th e claim. | |
| 4231 | Storage: | |
| 4232 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4233 | Field: PRO VIDER ID T YPE (#.06) | |
| 4234 | Code Set C hange: | |
| 4235 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4236 | 5 | |
| 4237 | Operating Phy Sec ID (2) | |
| 4238 | 30 A/N | |
| 4239 | 837: (I) 2 310B REF02 | |
| 4240 | Print: N/A | |
| 4241 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4242 | Billers ad d the prov ider to th e claim. | |
| 4243 | Storage: | |
| 4244 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4245 | Field: PRO VIDER ID ( #.07) | |
| 4246 | ||
| 4247 | 6 | |
| 4248 | Operating Phy Sec ID Qualifier (3) | |
| 4249 | 2 A/N | |
| 4250 | 837: (I) 2 310B REF01 | |
| 4251 | Print: N/A | |
| 4252 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4253 | Billers ad d the prov ider to th e claim. | |
| 4254 | Storage: | |
| 4255 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4256 | Field: PRO VIDER ID T YPE (#.06) | |
| 4257 | Code Set C hange: | |
| 4258 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4259 | 7 | |
| 4260 | Operating Phy Sec ID (3) | |
| 4261 | 30 A/N | |
| 4262 | 837: (I) 2 310B REF02 | |
| 4263 | Print: N/A | |
| 4264 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4265 | Billers ad d the prov ider to th e claim. | |
| 4266 | Storage: | |
| 4267 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4268 | Field: PRO VIDER ID ( #.07) | |
| 4269 | ||
| 4270 | 8 | |
| 4271 | Operating Phy Sec ID Qualifier (4) | |
| 4272 | 2 A/N | |
| 4273 | 837: (I) 2 310B REF01 | |
| 4274 | Print: N/A | |
| 4275 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4276 | Billers ad d the prov ider to th e claim. | |
| 4277 | Storage: | |
| 4278 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4279 | Field: PRO VIDER ID T YPE (#.06) | |
| 4280 | Code Set C hange: | |
| 4281 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4282 | 9 | |
| 4283 | Operating Phy Sec ID (4) | |
| 4284 | 30 A/N | |
| 4285 | 837: (I) 2 310B REF02 | |
| 4286 | Print: N/A | |
| 4287 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4288 | Billers ad d the prov ider to th e claim. | |
| 4289 | Storage: | |
| 4290 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4291 | Field: PRO VIDER ID ( #.07) | |
| 4292 | ||
| 4293 | ||
| 4294 | OPR4 - Loo p 2310C (O ther Opera ting Provi der Second ary ID Dat a) [SEQ 10 0] | |
| 4295 | One record per Claim Data reco rd | |
| 4296 | (Optional – Max len gth 141 by tes) | |
| 4297 | Piece | |
| 4298 | Descriptio n | |
| 4299 | Max Length Data Type | |
| 4300 | 837/Print Location | |
| 4301 | VistA Inpu t/Storage | |
| 4302 | FSC Proces sing Comme nts | |
| 4303 | 1 | |
| 4304 | RECORD ID = ‘OPR4 ’ | |
| 4305 | 4 A | |
| 4306 | ||
| 4307 | ||
| 4308 | ||
| 4309 | 2 | |
| 4310 | Other Oper ating Prov Sec ID Qu alifier (1 ) | |
| 4311 | ||
| 4312 | 2 A/N | |
| 4313 | 837: (I) 2 310C REF01 | |
| 4314 | Print: | |
| 4315 | UB04 – FL7 8 | |
| 4316 | Note: G2 o r 1G ID us ed if no I D provided by the In surance Co mpany is f ound | |
| 4317 | ||
| 4318 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4319 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4320 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4321 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4322 | Storage: | |
| 4323 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4324 | Or by Care Unit | |
| 4325 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4326 | Field: PRO VIDER ID T YPE (#.06) | |
| 4327 | Code Set C hange: | |
| 4328 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4329 | 3 | |
| 4330 | Other Oper ating Prov Sec ID (1 ) | |
| 4331 | 30 A/N | |
| 4332 | 837: (I) 2 310C REF02 | |
| 4333 | Print: | |
| 4334 | UB04 – FL7 8 | |
| 4335 | ||
| 4336 | Note: The software l ooks for t he first c ompliant s econdary I D to print . Only one Secondary ID prints in FL78. | |
| 4337 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4338 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4339 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4340 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4341 | Storage: | |
| 4342 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4343 | Or by Care Unit | |
| 4344 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4345 | Field: PRO VIDER ID ( #.07) | |
| 4346 | None | |
| 4347 | 4 | |
| 4348 | Other Oper ating Prov Sec ID Qu alifier (2 ) | |
| 4349 | 2 A/N | |
| 4350 | 837: (I) 2 310C REF01 | |
| 4351 | Print: N/A | |
| 4352 | ||
| 4353 | Note: The software l ooks for t he first c ompliant s econdary I D to print . Only one Secondary ID prints in FL78. | |
| 4354 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4355 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4356 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4357 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4358 | Storage: | |
| 4359 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4360 | Or by Care Unit | |
| 4361 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4362 | Field: PRO VIDER ID T YPE (#.06) | |
| 4363 | Code Set C hange: | |
| 4364 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4365 | 5 | |
| 4366 | Other Oper ating Prov Sec ID (2 ) | |
| 4367 | 30 A/N | |
| 4368 | 837: (I) 2 310C REF02 | |
| 4369 | Print: N/A | |
| 4370 | ||
| 4371 | Note: The software l ooks for t he first c ompliant s econdary I D to print . Only one Secondary ID prints in FL78. | |
| 4372 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4373 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4374 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4375 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4376 | Storage: | |
| 4377 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4378 | Or by Care Unit | |
| 4379 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4380 | Field: PRO VIDER ID ( #.07) | |
| 4381 | None | |
| 4382 | 6 | |
| 4383 | Other Oper ating Prov Sec ID Qu alifier (3 ) | |
| 4384 | 2 A/N | |
| 4385 | 837: (I) 2 310C REF01 | |
| 4386 | Print: N/A | |
| 4387 | ||
| 4388 | Note: The software l ooks for t he first c ompliant s econdary I D to print . Only one Secondary ID prints in FL78. | |
| 4389 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4390 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4391 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4392 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4393 | Storage: | |
| 4394 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4395 | Or by Care Unit | |
| 4396 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4397 | Field: PRO VIDER ID T YPE (#.06) | |
| 4398 | Code Set C hange: | |
| 4399 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4400 | 7 | |
| 4401 | Other Oper ating Prov Sec ID (3 ) | |
| 4402 | 30 A/N | |
| 4403 | 837: (I) 2 310C REF02 | |
| 4404 | Print: N/A | |
| 4405 | ||
| 4406 | Note: The software l ooks for t he first c ompliant s econdary I D to print . Only one Secondary ID prints in FL78. | |
| 4407 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4408 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4409 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4410 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4411 | Storage: | |
| 4412 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4413 | Or by Care Unit | |
| 4414 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4415 | Field: PRO VIDER ID ( #.07) | |
| 4416 | None | |
| 4417 | 8 | |
| 4418 | Other Oper ating Prov Sec ID Qu alifier (4 ) | |
| 4419 | 2 A/N | |
| 4420 | 837: (I) 2 310C REF01 | |
| 4421 | Print: N/A | |
| 4422 | ||
| 4423 | Note: The software l ooks for t he first c ompliant s econdary I D to print . Only one Secondary ID prints in FL78. | |
| 4424 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4425 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4426 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4427 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4428 | Storage: | |
| 4429 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4430 | Or by Care Unit | |
| 4431 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4432 | Field: PRO VIDER ID T YPE (#.06) | |
| 4433 | ||
| 4434 | Code Set C hange: | |
| 4435 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4436 | 9 | |
| 4437 | Other Oper ating Prov Sec ID (4 ) | |
| 4438 | 30 A/N | |
| 4439 | 837: (I) 2 310C REF02 | |
| 4440 | Print: N/A | |
| 4441 | ||
| 4442 | Note: The software l ooks for t he first c ompliant s econdary I D to print . Only one Secondary ID prints in FL78. | |
| 4443 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4444 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4445 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4446 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4447 | Storage: | |
| 4448 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4449 | Or by Care Unit | |
| 4450 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4451 | Field: PRO VIDER ID ( #.07) | |
| 4452 | None | |
| 4453 | ||
| 4454 | OPR5 - Loo p 2310A (R eferring P rovider Se condary ID Data) [SE Q 101] | |
| 4455 | One record per Claim Data reco rd | |
| 4456 | (OPTIONAL – Max leng th 107 byt es) | |
| 4457 | Piece | |
| 4458 | Descriptio n | |
| 4459 | Max Length Data Type | |
| 4460 | 837/Print Location | |
| 4461 | VistA Inpu t/Storage | |
| 4462 | FSC Proces sing Comme nts | |
| 4463 | 1 | |
| 4464 | RECORD ID = ‘OPR5 ’ | |
| 4465 | 4 A | |
| 4466 | ||
| 4467 | ||
| 4468 | ||
| 4469 | 2 | |
| 4470 | Referring Prov Sec I D Qualifie r (1) | |
| 4471 | ||
| 4472 | 2 A/N | |
| 4473 | 837: | |
| 4474 | (P) 2310A REF01 | |
| 4475 | (I) 2310F REF01 | |
| 4476 | Print: | |
| 4477 | CMS 1500 – Box 17a | |
| 4478 | UB04 – FL7 8/79 | |
| 4479 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4480 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4481 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4482 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4483 | Storage: | |
| 4484 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4485 | Or by Care Unit | |
| 4486 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4487 | Field: PRO VIDER ID T YPE (#.06) | |
| 4488 | Code Set Change: | |
| 4489 | Only codes now allow ed are 0B, 1G and G2 . | |
| 4490 | 3 | |
| 4491 | Referring Prov Sec I D (1) | |
| 4492 | 30 A/N | |
| 4493 | 837: | |
| 4494 | (P) 2310A REF02 | |
| 4495 | (I) 2310F REF02 | |
| 4496 | Print: | |
| 4497 | CMS 1500 – Box 17a | |
| 4498 | UB04 – FL7 8/79 | |
| 4499 | ||
| 4500 | Note: The software l ooks for t he first c ompliant s econdary I D to print . Only one Secondary ID prints in Box 19 /FL78/79 | |
| 4501 | ||
| 4502 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4503 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4504 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4505 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4506 | Storage: | |
| 4507 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4508 | Or by Care Unit | |
| 4509 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4510 | Field: PRO VIDER ID ( #.07) | |
| 4511 | None | |
| 4512 | 4 | |
| 4513 | Referring Prov Sec I D Qualifie r (2) | |
| 4514 | 2 A/N | |
| 4515 | 837: | |
| 4516 | (P) 2310A REF01 | |
| 4517 | (I) 2310F REF01 | |
| 4518 | Print: N/A | |
| 4519 | Note: The software l ooks for t he first c ompliant s econdary I D to print . Only one Secondary ID prints in Box 19 /FL78/79 | |
| 4520 | ||
| 4521 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4522 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4523 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4524 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4525 | Storage: | |
| 4526 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4527 | Or by Care Unit | |
| 4528 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4529 | Field: PRO VIDER ID T YPE (#.06) | |
| 4530 | Code Set C hange: | |
| 4531 | Only codes now allow ed are 0B, 1G and G2 . | |
| 4532 | 5 | |
| 4533 | Referring Prov Sec I D (2) | |
| 4534 | 30 A/N | |
| 4535 | 837: | |
| 4536 | (P) 2310A REF02 | |
| 4537 | (I) 2310F REF02 | |
| 4538 | Print: N/A | |
| 4539 | Note: The software l ooks for t he first c ompliant s econdary I D to print . Only one Secondary ID prints in Box 19 /FL78/79 | |
| 4540 | ||
| 4541 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4542 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4543 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4544 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4545 | Storage: | |
| 4546 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4547 | Or by Care Unit | |
| 4548 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4549 | Field: PRO VIDER ID ( #.07) | |
| 4550 | None | |
| 4551 | 6 | |
| 4552 | Referring Prov Sec I D Qualifie r (3) | |
| 4553 | 2 A/N | |
| 4554 | ||
| 4555 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4556 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4557 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4558 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4559 | Storage: | |
| 4560 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4561 | Or by Care Unit | |
| 4562 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4563 | Field: PRO VIDER ID T YPE (#.06) | |
| 4564 | Code Set C hange: | |
| 4565 | Only codes now allow ed are 0B, 1G and G2 . | |
| 4566 | 7 | |
| 4567 | Referring Prov Sec I D (3) | |
| 4568 | 30 A/N | |
| 4569 | 837: | |
| 4570 | (P) 2310A REF02 | |
| 4571 | (I) 2310F REF01 | |
| 4572 | Print: N/A | |
| 4573 | Note: The software l ooks for t he first c ompliant s econdary I D to print . Only one Secondary ID prints in Box 19 /FL78/79 | |
| 4574 | ||
| 4575 | ||
| 4576 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4577 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4578 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4579 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4580 | Storage: | |
| 4581 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4582 | Or by Care Unit | |
| 4583 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4584 | Field: PRO VIDER ID ( #.07) | |
| 4585 | ||
| 4586 | ||
| 4587 | OPR7 - Loo p 2310E (S upervising Provider Data) [SEQ 103] | |
| 4588 | One record per Claim Data reco rd | |
| 4589 | (OPTIONAL – Max leng th 137 byt es) | |
| 4590 | Piece | |
| 4591 | Descriptio n | |
| 4592 | Max Length Data Type | |
| 4593 | 837/Print Location | |
| 4594 | VistA Inpu t/Storage | |
| 4595 | FSC Proces sing Comme nts | |
| 4596 | 1 | |
| 4597 | RECORD ID = ‘OPR7’ | |
| 4598 | 4 A | |
| 4599 | N/A | |
| 4600 | ||
| 4601 | ||
| 4602 | 2 | |
| 4603 | Supervisin g Prov Las t Name | |
| 4604 | 35 A/N | |
| 4605 | 837: (P) 2 310D NM103 | |
| 4606 | Print: N/A | |
| 4607 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4608 | Storage: | |
| 4609 | File: BILL /CLAIMS (# 399) | |
| 4610 | Subfile: P ROVIDER (# 222) | |
| 4611 | Field: PER FORMED BY (#.02) | |
| 4612 | 837P: Loop Change to 2310D. | |
| 4613 | Maximum HI PAA length increased to 60 | |
| 4614 | Set NM101 = DQ | |
| 4615 | NM102 = 1. | |
| 4616 | 3 | |
| 4617 | Supervisin g Prov Fir st Name | |
| 4618 | 25 A/N | |
| 4619 | 837: (P) 2 310D NM104 | |
| 4620 | Print: N/A | |
| 4621 | ||
| 4622 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4623 | Storage: | |
| 4624 | File: BILL /CLAIMS (# 399) | |
| 4625 | Subfile: P ROVIDER (# 222) | |
| 4626 | Field: PER FORMED BY (#.02) | |
| 4627 | 837P: Loop Change to 2310D. | |
| 4628 | Maximum HI PAA length increased to 35. | |
| 4629 | 4 | |
| 4630 | Supervisin g Prov Mid dle Name | |
| 4631 | 25 A/N | |
| 4632 | 837: (P) 2 310D NM105 | |
| 4633 | Print: N/A | |
| 4634 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4635 | Storage: | |
| 4636 | File: BILL /CLAIMS (# 399) | |
| 4637 | Subfile: P ROVIDER (# 222) | |
| 4638 | Field: PER FORMED BY (#.02) | |
| 4639 | 837P: Loop Change to 2310D. | |
| 4640 | 5 | |
| 4641 | Supervisin g Prov Nam e Suffix | |
| 4642 | 10 A/N | |
| 4643 | 837: (P) 2 310D NM107 | |
| 4644 | Print: N/A | |
| 4645 | ||
| 4646 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4647 | Storage: | |
| 4648 | File: BILL /CLAIMS (# 399) | |
| 4649 | Subfile: P ROVIDER (# 222) | |
| 4650 | Field: PER FORMED BY (#.02) | |
| 4651 | 837P: Loo p Change t o 2310D. | |
| 4652 | 6 | |
| 4653 | Supervisin g Prov Pri mary ID Qu alifier | |
| 4654 | 2 A | |
| 4655 | 837: (P) 2 310D NM108 | |
| 4656 | Print: N/A | |
| 4657 | ||
| 4658 | Biller Inp ut: N/A | |
| 4659 | Storage: N /A | |
| 4660 | Note: Alwa ys XX | |
| 4661 | 837P: Loop Change fr om to 2310 D. | |
| 4662 | 7 | |
| 4663 | Supervisin g Provider Primary I D | |
| 4664 | 30 A/N | |
| 4665 | 837: (P) 2 310D NM109 | |
| 4666 | Print: N/A | |
| 4667 | Biller Inp ut: N/A | |
| 4668 | The biller can add a provider to a claim but the p rovider’s NPI comes from the N ew Person file. | |
| 4669 | Storage: | |
| 4670 | File: NEW PERSON (#2 00) | |
| 4671 | Field: NPI (#41.99) | |
| 4672 | 837P: Loop Change to 2310D. | |
| 4673 | ||
| 4674 | ||
| 4675 | OPR8 - Loo p 2310E (S upervising Provider Secondary ID Data) [ SEQ 104] | |
| 4676 | One record per Claim Data reco rd | |
| 4677 | (OPTIONAL – Max leng th 104 byt es) | |
| 4678 | Piece | |
| 4679 | Descriptio n | |
| 4680 | Max Length Data Type | |
| 4681 | 837/Print Location | |
| 4682 | VistA Inpu t/Storage | |
| 4683 | FSC Proces sing Comme nts | |
| 4684 | 1 | |
| 4685 | RECORD ID = ‘OPR8’ | |
| 4686 | 4 A | |
| 4687 | N/A | |
| 4688 | ||
| 4689 | ||
| 4690 | 2 | |
| 4691 | Supervisin g Prov Sec ID Qualif ier (1) | |
| 4692 | 2 A/N | |
| 4693 | 837: | |
| 4694 | (P) 2310D REF01 | |
| 4695 | Print: N/A | |
| 4696 | ||
| 4697 | ||
| 4698 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4699 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4700 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4701 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4702 | Storage: | |
| 4703 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4704 | Or by Care Unit | |
| 4705 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4706 | Field: PRO VIDER ID T YPE (#.06) | |
| 4707 | Code Set C hange: | |
| 4708 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4709 | 837P: Loop Change to 2310D. | |
| 4710 | 3 | |
| 4711 | Supervisin g Prov Sec ID (1) | |
| 4712 | 30 A/N | |
| 4713 | 837: (P) 2 310D REF02 | |
| 4714 | Print: N/A | |
| 4715 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4716 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4717 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4718 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4719 | Storage: | |
| 4720 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4721 | Or by Care Unit | |
| 4722 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4723 | Field: PRO VIDER ID ( #.07) | |
| 4724 | 837P: Loo p Change t o 2310D. | |
| 4725 | 4 | |
| 4726 | Supervisin g Prov Sec ID Qualif ier (2) | |
| 4727 | 2 A/N | |
| 4728 | 837: (P) 2 310D REF01 | |
| 4729 | Print: N/A | |
| 4730 | ||
| 4731 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4732 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4733 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4734 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4735 | Storage: | |
| 4736 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4737 | Or by Care Unit | |
| 4738 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4739 | Field: PRO VIDER ID T YPE (#.06) | |
| 4740 | 837P: Loop Change to 2310D. | |
| 4741 | Code Set C hange: | |
| 4742 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4743 | 5 | |
| 4744 | Supervisin g Prov Sec ID (2) | |
| 4745 | 30 A/N | |
| 4746 | 837: (P) 2 310D REF02 | |
| 4747 | Print: N/A | |
| 4748 | ||
| 4749 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4750 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4751 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4752 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4753 | Storage: | |
| 4754 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4755 | Or by Care Unit | |
| 4756 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4757 | Field: PRO VIDER ID ( #.07) | |
| 4758 | 837P: Loo p Change t o 2310D. | |
| 4759 | 6 | |
| 4760 | Supervisin g Prov Sec ID Qualif ier (3) | |
| 4761 | 2 A/N | |
| 4762 | 837: (P) 2 310D REF01 | |
| 4763 | Print: N/A | |
| 4764 | ||
| 4765 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4766 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4767 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4768 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4769 | Storage: | |
| 4770 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4771 | Or by Care Unit | |
| 4772 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4773 | Field: PRO VIDER ID T YPE (#.06) | |
| 4774 | Code Set C hange: | |
| 4775 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4776 | 837P: Loop Change to 2310D. | |
| 4777 | 7 | |
| 4778 | Supervisin g Prov Sec ID (3) | |
| 4779 | 30 A/N | |
| 4780 | 837: (P) 2 310D REF02 | |
| 4781 | Print: N/A | |
| 4782 | ||
| 4783 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4784 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4785 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4786 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4787 | Storage: | |
| 4788 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4789 | Or by Care Unit | |
| 4790 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4791 | Field: PRO VIDER ID ( #.07) | |
| 4792 | 837P: Loo p Change t o 2310D. | |
| 4793 | 8 | |
| 4794 | Supervisin g Prov Sec ID Qualif ier (4) | |
| 4795 | 2 A/N | |
| 4796 | 837: (P) 2 310D REF01 | |
| 4797 | Print: N/A | |
| 4798 | ||
| 4799 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4800 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4801 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4802 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4803 | Storage: | |
| 4804 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4805 | Or by Care Unit | |
| 4806 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4807 | Field: PRO VIDER ID T YPE (#.06) | |
| 4808 | Code Set C hange: | |
| 4809 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 4810 | 837P: Loop Change to 2310D. | |
| 4811 | 9 | |
| 4812 | Supervisin g Prov Sec ID (4) | |
| 4813 | 30 A/N | |
| 4814 | 837: (P) 2 310D REF02 | |
| 4815 | Print: N/A | |
| 4816 | ||
| 4817 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4818 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4819 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4820 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4821 | Storage: | |
| 4822 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 4823 | Or by Care Unit | |
| 4824 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 4825 | Field: PRO VIDER ID ( #.07) | |
| 4826 | 837P: Loo p Change t o 2310D. | |
| 4827 | ||
| 4828 | OPR9 – Loo p 2310B/23 10D (Rende ring Provi der Data) [SEQ 104.5 ] | |
| 4829 | One record per Claim Data reco rd | |
| 4830 | (OPTIONAL – Max leng th 156 byt es) | |
| 4831 | Piece | |
| 4832 | Descriptio n | |
| 4833 | Max Length Data Type | |
| 4834 | 837/Print Location | |
| 4835 | VistA Inpu t/Storage | |
| 4836 | FSC Proces sing Comme nts | |
| 4837 | 1 | |
| 4838 | RECORD ID = ‘OPR9’ | |
| 4839 | 4 A | |
| 4840 | N/A | |
| 4841 | ||
| 4842 | ||
| 4843 | 2 | |
| 4844 | Rendering Provider Q ualifier | |
| 4845 | 2 N | |
| 4846 | 837: | |
| 4847 | (I) 2310D NM101 | |
| 4848 | (P)2310B N M101 | |
| 4849 | Print: N/A | |
| 4850 | Biller Inp ut: N/A | |
| 4851 | Storage: N /A | |
| 4852 | Note: Alwa ys 82 | |
| 4853 | ||
| 4854 | 3 | |
| 4855 | Rendering Provider T ype | |
| 4856 | 1 N | |
| 4857 | 837: | |
| 4858 | (I) 2310D NM102 | |
| 4859 | (P)2310B N M102 | |
| 4860 | Print: N/A | |
| 4861 | Biller Inp ut: N/A | |
| 4862 | Storage: N /A | |
| 4863 | Note: Alwa ys 1 | |
| 4864 | ||
| 4865 | 4 | |
| 4866 | Rendering Provider L ast Name | |
| 4867 | 35 A/N | |
| 4868 | 837: | |
| 4869 | (I) 2310D NM103 | |
| 4870 | (P)2310B N M103 | |
| 4871 | Print: | |
| 4872 | CMS 1500 – Box 31 as signature | |
| 4873 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4874 | Storage: | |
| 4875 | File: BILL /CLAIMS (# 399) | |
| 4876 | Subfile: P ROVIDER (# 222) | |
| 4877 | Field: PER FORMED BY (#.02) | |
| 4878 | ||
| 4879 | 5 | |
| 4880 | Rendering Provider F irst Name | |
| 4881 | 25 A/N | |
| 4882 | 837: | |
| 4883 | (I) 2310D NM104 | |
| 4884 | (P) 2310B NM104 | |
| 4885 | Print: | |
| 4886 | CMS 1500 – Box 31 as signature | |
| 4887 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4888 | Storage: | |
| 4889 | File: BILL /CLAIMS (# 399) | |
| 4890 | Subfile: P ROVIDER (# 222) | |
| 4891 | Field: PER FORMED BY (#.02) | |
| 4892 | Maximum HI PAA length increased to 35. | |
| 4893 | 6 | |
| 4894 | Rendering Provider M iddle Name | |
| 4895 | 25 A/N | |
| 4896 | 837: | |
| 4897 | (I) 2310D NM105 | |
| 4898 | (P) 2310B NM105 | |
| 4899 | Print: | |
| 4900 | CMS 1500 – Box 31 as signature | |
| 4901 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4902 | Storage: | |
| 4903 | File: BILL /CLAIMS (# 399) | |
| 4904 | Subfile: P ROVIDER (# 222) | |
| 4905 | Field: PER FORMED BY (#.02) | |
| 4906 | ||
| 4907 | 7 | |
| 4908 | Rendering Provider N ame Suffix | |
| 4909 | 10 A/N | |
| 4910 | 837: | |
| 4911 | (I) 2310D NM107 | |
| 4912 | (P) 2310B NM107 | |
| 4913 | Print: | |
| 4914 | CMS 1500 – Box 31 as signature | |
| 4915 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4916 | Storage: | |
| 4917 | File: BILL /CLAIMS (# 399) | |
| 4918 | Subfile: P ROVIDER (# 222) | |
| 4919 | Field: PER FORMED BY (#.02) | |
| 4920 | ||
| 4921 | 8 | |
| 4922 | Rendering Provider Primary ID Qualifier | |
| 4923 | 2 A | |
| 4924 | 837: | |
| 4925 | (I) 2310D NM108 | |
| 4926 | (P) 2310B NM108 | |
| 4927 | Print: Pre printed | |
| 4928 | Biller Inp ut: N/A | |
| 4929 | Storage: N /A | |
| 4930 | Note: Alwa ys XX | |
| 4931 | ||
| 4932 | 9 | |
| 4933 | Rendering Provider P rimary ID | |
| 4934 | 30 A/N | |
| 4935 | 837: | |
| 4936 | (I) 2310D NM109 | |
| 4937 | (P) 2310B NM109 | |
| 4938 | Print: | |
| 4939 | CMS 1500 – Box 24J | |
| 4940 | UB04 – FL7 8/79 | |
| 4941 | Biller Inp ut: N/A | |
| 4942 | The biller can add a provider to a claim but the p rovider’s NPI comes from the N ew Person file. | |
| 4943 | Storage: | |
| 4944 | File: NEW PERSON (#2 00) | |
| 4945 | Field: NPI (#41.99) | |
| 4946 | ||
| 4947 | 10 | |
| 4948 | Rend Prov Taxonomy Q ualifier | |
| 4949 | 2 A/N | |
| 4950 | 837: (P)23 10B PRV01 | |
| 4951 | Print: N/A | |
| 4952 | Biller Inp ut: N/A | |
| 4953 | Storage: N /A | |
| 4954 | Note: Alwa ys PE | |
| 4955 | 837I not u sed for re ndering pr ovider | |
| 4956 | 11 | |
| 4957 | Rend Prov Taxonomy | |
| 4958 | 10 A/N | |
| 4959 | 837: (P)23 10B PRV03 | |
| 4960 | Print: N/A | |
| 4961 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4962 | The physic ian’s taxo nomy code is default ed from th e New Pers on file bu t may be o verridden by the bil ler. | |
| 4963 | Storage: | |
| 4964 | File: BILL /CLAIMS (# 399) | |
| 4965 | Subfile: P ROVIDER (# 222) | |
| 4966 | Field: TAX ONOMY (#.1 5) | |
| 4967 | Set PRV02 = PXC. | |
| 4968 | 837I not u sed for re ndering pr ovider | |
| 4969 | ||
| 4970 | OPRA – Loo p 2310B/23 10D (Rende ring Provi der Second ary ID) [ SEQ 104.4] | |
| 4971 | One record per Claim Data reco rd | |
| 4972 | (OPTIONAL – Max leng th 140 byt es) | |
| 4973 | Piece | |
| 4974 | Descriptio n | |
| 4975 | Max Length Data Type | |
| 4976 | 837/Print Location | |
| 4977 | VistA Inpu t/Storage | |
| 4978 | FSC Proces sing Comme nts | |
| 4979 | 1 | |
| 4980 | RECORD ID = ‘OPRA’ | |
| 4981 | 4 A | |
| 4982 | N/A | |
| 4983 | ||
| 4984 | ||
| 4985 | 2 | |
| 4986 | Rendering Provider S ec ID Qual ifier (1) | |
| 4987 | 2 A | |
| 4988 | 837: | |
| 4989 | (I) 2310D REF01 | |
| 4990 | (P) 2310B REF01 | |
| 4991 | Print: | |
| 4992 | CMS 1500 – Box 24I, 1-6 | |
| 4993 | ||
| 4994 | Note: The software l ooks for t he first c ompliant s econdary I D to print . | |
| 4995 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 4996 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 4997 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 4998 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 4999 | Storage: | |
| 5000 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 5001 | Or by Care Unit | |
| 5002 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 5003 | Field: PRO VIDER ID T YPE (#.06) | |
| 5004 | ||
| 5005 | 3 | |
| 5006 | Rendering Provider S ec ID (1) | |
| 5007 | 30 A/N | |
| 5008 | 837: | |
| 5009 | (I) 2310D REF02 | |
| 5010 | (P) 2310B REF02 | |
| 5011 | Print: | |
| 5012 | CMS 1500 – Box 24J, 1-6 | |
| 5013 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 5014 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 5015 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 5016 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 5017 | Storage: | |
| 5018 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 5019 | Or by Care Unit | |
| 5020 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 5021 | Field: PRO VIDER ID ( #.07) | |
| 5022 | ||
| 5023 | 4 | |
| 5024 | Rendering Provider S ec ID Qual ifier (2) | |
| 5025 | 2 A | |
| 5026 | 837: | |
| 5027 | (I) 2310D REF01 | |
| 5028 | (P) 2310B REF01 | |
| 5029 | Print: N/A | |
| 5030 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 5031 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 5032 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 5033 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 5034 | Storage: | |
| 5035 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 5036 | Or by Care Unit | |
| 5037 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 5038 | Field: PRO VIDER ID T YPE (#.06) | |
| 5039 | ||
| 5040 | 5 | |
| 5041 | Rendering Provider S ec ID (2) | |
| 5042 | 30 A/N | |
| 5043 | 837: | |
| 5044 | (I) 2310D REF02 | |
| 5045 | (P) 2310B REF02 | |
| 5046 | Print: N/A | |
| 5047 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 5048 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 5049 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 5050 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 5051 | Storage: | |
| 5052 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 5053 | Or by Care Unit | |
| 5054 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 5055 | Field: PRO VIDER ID ( #.07) | |
| 5056 | ||
| 5057 | 6 | |
| 5058 | Rendering Provider S ec ID Qual ifier (3) | |
| 5059 | 2 A | |
| 5060 | 837: | |
| 5061 | (I) 2310D REF01 | |
| 5062 | (P) 2310B REF01 | |
| 5063 | Print: N/A | |
| 5064 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 5065 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 5066 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 5067 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 5068 | Storage: | |
| 5069 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 5070 | Or by Care Unit | |
| 5071 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 5072 | Field: PRO VIDER ID T YPE (#.06) | |
| 5073 | ||
| 5074 | 7 | |
| 5075 | Rendering Provider S ec ID (3) | |
| 5076 | 30 A/N | |
| 5077 | 837: | |
| 5078 | (I) 2310D REF02 | |
| 5079 | (P) 2310B REF02 | |
| 5080 | Print: N/A | |
| 5081 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 5082 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 5083 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 5084 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 5085 | Storage: | |
| 5086 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 5087 | Or by Care Unit | |
| 5088 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 5089 | Field: PRO VIDER ID ( #.07) | |
| 5090 | ||
| 5091 | 8 | |
| 5092 | Rendering Provider S ec ID Qual ifier (4) | |
| 5093 | 2 A | |
| 5094 | 837: | |
| 5095 | (I) 2310D REF01 | |
| 5096 | (P) 2310B REF01 | |
| 5097 | Print: N/A | |
| 5098 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 5099 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 5100 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 5101 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 5102 | Storage: | |
| 5103 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 5104 | Or by Care Unit | |
| 5105 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 5106 | Field: PRO VIDER ID T YPE (#.06) | |
| 5107 | ||
| 5108 | 9 | |
| 5109 | Rendering Provider S ec ID (4) | |
| 5110 | 30 A/N | |
| 5111 | 837: | |
| 5112 | (I) 2310D REF02 | |
| 5113 | (P) 2310B REF02 | |
| 5114 | Print: N/A | |
| 5115 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 5116 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 5117 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 5118 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 5119 | Storage: | |
| 5120 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 5121 | Or by Care Unit | |
| 5122 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 5123 | Field: PRO VIDER ID ( #.07) | |
| 5124 | ||
| 5125 | ||
| 5126 | ||
| 5127 | ||
| 5128 | AMB - Loop 2310E/F ( Ambulance Pick-up / Drop-off) [SEQ 104.8 ] | |
| 5129 | Repeat x 2 : Ambulanc e pick-up is sent in the 2310E while dro p-off is i n the 2310 F. When se nding both data elem ents the p ickup loca tion shoul d be first . | |
| 5130 | (Optional – Max len gth 190 by tes) | |
| 5131 | Piece | |
| 5132 | Descriptio n | |
| 5133 | Max Length Data Type | |
| 5134 | 837/Print Location | |
| 5135 | VistA Inpu t/Storage | |
| 5136 | FSC Proces sing Comme nts | |
| 5137 | 1 | |
| 5138 | RECORD ID = ‘AMB’ | |
| 5139 | 4 A | |
| 5140 | ||
| 5141 | ||
| 5142 | ||
| 5143 | 2 | |
| 5144 | Address Ty pe Qualifi er | |
| 5145 | 2 A/N | |
| 5146 | 837: | |
| 5147 | P)2310E / 2310F NM10 1 | |
| 5148 | Print: N/A | |
| 5149 | Biller Inp ut: N/A | |
| 5150 | Screen 9 S ection 1 | |
| 5151 | The system adds the Qualifier automatica lly. | |
| 5152 | Equal to P W for pick up or | |
| 5153 | 45 for Dro p off | |
| 5154 | Set NM102 = 2 | |
| 5155 | 3 | |
| 5156 | Ambulance Address Li ne 1 | |
| 5157 | 40 A/N | |
| 5158 | 837: | |
| 5159 | (P)2310E / 2310F N301 | |
| 5160 | Print: N/A | |
| 5161 | Biller Inp ut: Screen 9 Section 1 | |
| 5162 | Storage: | |
| 5163 | File: Bill /Claims (# 399) | |
| 5164 | Field: AMB ULANCE P/U ADDRESS 1 (#271) | |
| 5165 | Field: AMB ULANCE D/O ADDRESS 1 (#277) | |
| 5166 | ||
| 5167 | 4 | |
| 5168 | Ambulance Address Li ne 2 | |
| 5169 | 30 A/N | |
| 5170 | 837: | |
| 5171 | (P) 2310E /2310F N30 2 | |
| 5172 | Print: N/A | |
| 5173 | Biller Inp ut: Screen 9 Section 1 | |
| 5174 | Storage: | |
| 5175 | File: Bill /Claims (# 399) | |
| 5176 | Field: AMB ULANCE P/U ADDRESS 2 (#272) | |
| 5177 | Field: AMB ULANCE D/O ADDRESS 2 (#278) | |
| 5178 | ||
| 5179 | 5 | |
| 5180 | Ambulance City | |
| 5181 | 30 A/N | |
| 5182 | 837: | |
| 5183 | (P) 2310E 2310F N401 | |
| 5184 | Print: N/A | |
| 5185 | Biller Inp ut: Screen 9 Section 1 | |
| 5186 | Storage: | |
| 5187 | File: Bill /Claims (# 399) | |
| 5188 | Field: AMB ULANCE P/U CITY (#27 3) | |
| 5189 | Field: AMB ULANCE D/O CITY (#27 9) | |
| 5190 | None | |
| 5191 | 6 | |
| 5192 | Ambulance State | |
| 5193 | 2 A | |
| 5194 | 837: | |
| 5195 | (P) 2310E / 2310F N4 02 | |
| 5196 | Print: N/A | |
| 5197 | Biller Inp ut: Screen 9 Section 1 | |
| 5198 | Storage: | |
| 5199 | File: Bill /Claims (# 399) | |
| 5200 | Field: AMB ULANCE P/U STATE (#2 74) | |
| 5201 | Field: AMB ULANCE D/O STATE (#2 80) | |
| 5202 | None | |
| 5203 | 7 | |
| 5204 | Ambulance Zip | |
| 5205 | 15 A/N | |
| 5206 | 837: (P) 2 310E / 231 0F N403 | |
| 5207 | Print: N/A | |
| 5208 | Biller Inp ut: Screen 9 Section 1 | |
| 5209 | Storage: | |
| 5210 | File: Bill /Claims (# 399) | |
| 5211 | Field: AMB ULANCE P/U ZIP (#275 ) | |
| 5212 | Field: AMB ULANCE D/O ZIP (#281 ) | |
| 5213 | None | |
| 5214 | 8 | |
| 5215 | Ambulance Drop Off L ocation | |
| 5216 | 60 A/N | |
| 5217 | 837: (P) 2 310F NM103 | |
| 5218 | Print: N/A | |
| 5219 | Biller Inp ut: Screen 9 Section 1 | |
| 5220 | Storage: | |
| 5221 | File: Bill /Claims (# 399) | |
| 5222 | Field: AMB ULANCE P/U D/O LOCAT ION (#276) | |
| 5223 | Only used when NM101 = 45 | |
| 5224 | Note: Curr ently the pick-up re cord is se quence 104 .8 and the drop-off record is sequence 1 04.9. The two AMB r ecords wil l be merge d into one and will be control led by fie ld 2. | |
| 5225 | AMB1 - Loo p 2310E/F (Ambulance Pick-up / Drop-off) [SEQ 104 .9] | |
| 5226 | Repeat x 1 | |
| 5227 | (Optional – Max leng th 194 byt es) | |
| 5228 | Piece | |
| 5229 | Descriptio n | |
| 5230 | Max Length Data Type | |
| 5231 | 837/Print Location | |
| 5232 | VistA Inpu t/Storage | |
| 5233 | FSC Proces sing Comme nts | |
| 5234 | 1 | |
| 5235 | RECORD ID = ‘AMB1’ | |
| 5236 | 4 A | |
| 5237 | ||
| 5238 | ||
| 5239 | ||
| 5240 | 2 | |
| 5241 | Amb Patien t Weight U nits | |
| 5242 | 2 A | |
| 5243 | 837: (P) 2 300 CR101 | |
| 5244 | Print: N/A | |
| 5245 | Biller Inp ut: N/A | |
| 5246 | Storage: N /A | |
| 5247 | Note: Alwa ys LB | |
| 5248 | ||
| 5249 | 3 | |
| 5250 | Amb Patien t Weight | |
| 5251 | 3 N | |
| 5252 | 837: (P) 2 300 CR102 | |
| 5253 | Print: N/A | |
| 5254 | Biller Inp ut: Screen 9 Section 1 | |
| 5255 | Storage: | |
| 5256 | File: Bill /Claims (# 399) | |
| 5257 | Field: PAT IENT WEIGH T (#287) | |
| 5258 | ||
| 5259 | 4 | |
| 5260 | Amb Transp ort Reason Code | |
| 5261 | 1 A/N | |
| 5262 | 837: (P) 2 300 CR104 | |
| 5263 | Print: N/A | |
| 5264 | Biller Inp ut: Screen 9 Section 1 | |
| 5265 | Storage: | |
| 5266 | File: Bill /Claims (# 399) | |
| 5267 | Field: TRA NSPORT REA SON CODE ( #288) | |
| 5268 | ||
| 5269 | 5 | |
| 5270 | Amb Distan ce Units | |
| 5271 | 2 A | |
| 5272 | 837: (P) 2 300 CR105 | |
| 5273 | Print: N/A | |
| 5274 | Biller Inp ut: N/A | |
| 5275 | Storage: N /A | |
| 5276 | Note: Alwa ys DH | |
| 5277 | ||
| 5278 | 6 | |
| 5279 | Amb Transp ort Distan ce | |
| 5280 | 15 N | |
| 5281 | 837: (P) 2 300 CR106 | |
| 5282 | Print: N/A | |
| 5283 | Biller Inp ut: Screen 9 Section 1 | |
| 5284 | Storage: | |
| 5285 | File: Bill /Claims (# 399) | |
| 5286 | Field: AMB ULANCE TRA NSPORT DIS TANCE (#28 9) | |
| 5287 | ||
| 5288 | 7 | |
| 5289 | Amb Round Trip Purpo se | |
| 5290 | 80 A/N | |
| 5291 | 837: (P) 2 300 CR109 | |
| 5292 | Print: N/A | |
| 5293 | Biller Inp ut: Screen 9 Section 1 | |
| 5294 | Storage: | |
| 5295 | File: Bill /Claims (# 399) | |
| 5296 | Field: ROU ND TRIP PU RPOSE DESC RIPTION (# 290) | |
| 5297 | ||
| 5298 | 8 | |
| 5299 | Amb Stretc her Purpos e | |
| 5300 | 80 A/N | |
| 5301 | 837: (P) 2 300 CR110 | |
| 5302 | Print: N/A | |
| 5303 | Biller Inp ut: Screen 9 Section 1 | |
| 5304 | Storage: | |
| 5305 | File: Bill /Claims (# 399) | |
| 5306 | Field: STR ETCHER PUR POSE DESCR IPTION (#2 91) | |
| 5307 | ||
| 5308 | ||
| 5309 | AMB2 - Loo p 2300 (Am bulance Ce rtificatio n Data) [ SEQ 104.91 ] | |
| 5310 | Repeat x 3 | |
| 5311 | (Optional – Max leng th 36 byte s) | |
| 5312 | Piece | |
| 5313 | Descriptio n | |
| 5314 | Max Length Data Type | |
| 5315 | 837/Print Location | |
| 5316 | VistA Inpu t/Storage | |
| 5317 | FSC Proces sing Comme nts | |
| 5318 | 1 | |
| 5319 | RECORD ID = ‘AMB2’ | |
| 5320 | 4 A | |
| 5321 | ||
| 5322 | ||
| 5323 | ||
| 5324 | 2 | |
| 5325 | Amb Code C ategory | |
| 5326 | 2 N | |
| 5327 | 837: (P) 2 300 CRC01 | |
| 5328 | Print: N/A | |
| 5329 | Biller Inp ut: N/A | |
| 5330 | Storage: N /A | |
| 5331 | Note: Alwa ys 07 | |
| 5332 | ||
| 5333 | 3 | |
| 5334 | Amb Certif ication Co ndition In dicator | |
| 5335 | 1 A | |
| 5336 | 837: (P) 2 300 CRC02 | |
| 5337 | Print: N/A | |
| 5338 | Biller Inp ut: N/A | |
| 5339 | Storage: N /A | |
| 5340 | Note: Alwa ys Y for Y ES | |
| 5341 | ||
| 5342 | 4 | |
| 5343 | Amb Condit ion Code [ 1] | |
| 5344 | 3 A/N | |
| 5345 | 837: (P) 2 300 CRC03 | |
| 5346 | Print: N/A | |
| 5347 | Biller Inp ut: Screen 9 Section 2 | |
| 5348 | Storage: | |
| 5349 | File: Bill /Claims (# 399) | |
| 5350 | Subfile: A MBULANCE C ONDITION I NDICATOR ( #292) | |
| 5351 | Field: AMB ULANCE CON DITION IND ICATOR (#. 01) | |
| 5352 | ||
| 5353 | 5 | |
| 5354 | Amb Condit ion Code [ 2] | |
| 5355 | 3 A/N | |
| 5356 | 837: (P) 2 300 CRC04 | |
| 5357 | Print: N/A | |
| 5358 | Biller Inp ut: Screen 9 Section 2 | |
| 5359 | Storage: | |
| 5360 | File: Bill /Claims (# 399) | |
| 5361 | Subfile: A MBULANCE C ONDITION I NDICATOR ( #292) | |
| 5362 | Field: AMB ULANCE CON DITION IND ICATOR (#. 01) | |
| 5363 | ||
| 5364 | 6 | |
| 5365 | Amb Condit ion Code [ 3] | |
| 5366 | 3 A/N | |
| 5367 | 837: (P) 2 300 CRC05 | |
| 5368 | Print: N/A | |
| 5369 | Biller Inp ut: Screen 9 Section 2 | |
| 5370 | Storage: | |
| 5371 | File: Bill /Claims (# 399) | |
| 5372 | Subfile: A MBULANCE C ONDITION I NDICATOR ( #292) | |
| 5373 | Field: AMB ULANCE CON DITION IND ICATOR (#. 01) | |
| 5374 | ||
| 5375 | 7 | |
| 5376 | Amb Condit ion Code [ 4] | |
| 5377 | 3 A/N | |
| 5378 | 837: (P) 2 300 CRC06 | |
| 5379 | Print: N/A | |
| 5380 | Biller Inp ut: Screen 9 Section 2 | |
| 5381 | Storage: | |
| 5382 | File: Bill /Claims (# 399) | |
| 5383 | Subfile: A MBULANCE C ONDITION I NDICATOR ( #292) | |
| 5384 | Field: AMB ULANCE CON DITION IND ICATOR (#. 01) | |
| 5385 | ||
| 5386 | 8 | |
| 5387 | Amb Condit ion Code [ 5] | |
| 5388 | 3 A/N | |
| 5389 | 837: (P) 2 300 CRC07 | |
| 5390 | Print: N/A | |
| 5391 | Biller Inp ut: Screen 9 Section 2 | |
| 5392 | Storage: | |
| 5393 | File: Bill /Claims (# 399) | |
| 5394 | Subfile: A MBULANCE C ONDITION I NDICATOR ( #292) | |
| 5395 | Field: AMB ULANCE CON DITION IND ICATOR (#. 01) | |
| 5396 | ||
| 5397 | Section 4 – Other In surance Da ta | |
| 5398 | OI1 - Loop 2320/2330 B (Other S ubscriber and Other Payer Data ) [SEQ 105 ] | |
| 5399 | One or mor e records per Claim Data recor d set | |
| 5400 | (OPTIONAL – Max leng th 165 byt es) | |
| 5401 | Piece | |
| 5402 | Descriptio n | |
| 5403 | Max Length Data Type | |
| 5404 | 837/Print Location | |
| 5405 | VistA Inpu t/Storage | |
| 5406 | FSC Proces sing Comme nts | |
| 5407 | 1 | |
| 5408 | RECORD ID = ‘OI1 ’ | |
| 5409 | 4 A | |
| 5410 | ||
| 5411 | ||
| 5412 | ||
| 5413 | 2 | |
| 5414 | Payer Resp onsibility Sequence # Code | |
| 5415 | 1 A | |
| 5416 | 837: 2320 SBR01 | |
| 5417 | Print: N/A | |
| 5418 | Biller Inp ut: Screen 3 Section 1 | |
| 5419 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er is the destinatio n payer or the Other payers | |
| 5420 | Storage: | |
| 5421 | File: BILL /CLAIMS (# 399) | |
| 5422 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 5423 | Codes adde d to indic ate sequen ce out to 11 payers. VA will o nly use Pr imary (P), Secondary (S) ,Tert iary (T) | |
| 5424 | 3 | |
| 5425 | Individual Relations hip Code | |
| 5426 | 2 A/N | |
| 5427 | 837: 2320 SBR02 | |
| 5428 | Print: | |
| 5429 | CMS 1500 – Box 6 | |
| 5430 | UB04 – FL5 9 | |
| 5431 | Biller Inp ut: Screen 3 Section 1 | |
| 5432 | The policy is added to a bill on screen 3 but the payer must already e xist. | |
| 5433 | The Patien t’s Relati onship to Insured is selected when the p atient’s i nsurance p olicy is e nter in Pa tient Insu rance Info View/Edit . | |
| 5434 | File: PATI ENT (#2) | |
| 5435 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 5436 | Field: PT. RELATIONS HIP TO INS URED (#16) | |
| 5437 | Code list now only i ncludes 01 , 18, 19, 20, 21, 39 , 40, 53 a nd G8. | |
| 5438 | 4 | |
| 5439 | Other Grou p or Polic y # | |
| 5440 | 50 A/N | |
| 5441 | 837: 2320 SBR03 | |
| 5442 | Print: | |
| 5443 | CMS 1500 – Box 9a | |
| 5444 | UB04 – FL6 2 | |
| 5445 | Biller Inp ut: Screen 3 Section 1 | |
| 5446 | The policy is added to a bill on screen 3 but the payer must already e xist. | |
| 5447 | Insurance is entered for a spe cific pati ent in Pat ient Insur ance Info View/Edit. Once the insurance policy ex ists for a patient, it may be added to a bill and the system knows the policy na me and num ber. | |
| 5448 | Storage: | |
| 5449 | File – GRO UP INSURAN CE PLAN ( #355.3) | |
| 5450 | Field – GR OUP NUMBER (#.04) | |
| 5451 | Maximum HI PAA length increased to 50. | |
| 5452 | 5 | |
| 5453 | Other Grou p or Polic y Name | |
| 5454 | ||
| 5455 | 60 A/N | |
| 5456 | 837: 2320 SBR04 | |
| 5457 | Print: | |
| 5458 | CMS 1500 – Box 9d | |
| 5459 | UB04 – FL6 1 | |
| 5460 | Biller Inp ut: Screen 3 Section 1 | |
| 5461 | The policy is added to a bill on screen 3 but the payer must already e xist. | |
| 5462 | Insurance is entered for a spe cific pati ent in Pat ient Insur ance Info View/Edit. Once the insurance policy ex ists for a patient, it may be added to a bill and the system knows the policy na me and num ber. | |
| 5463 | Storage: | |
| 5464 | File - Ins urance Com pany (#36) | |
| 5465 | Subfile – GROUP INSU RANCE PLAN (#355.3) | |
| 5466 | Field – GR OUP NAME ( #.03) | |
| 5467 | ||
| 5468 | 6 | |
| 5469 | Other Paye r Last or Organizati on Name | |
| 5470 | 35 A/N | |
| 5471 | 837: 2330B NM103 | |
| 5472 | Print: | |
| 5473 | CMS 1500 – Box 9d | |
| 5474 | UB04 – FL5 0 | |
| 5475 | Biller Inp ut: Screen 3 Section 1 | |
| 5476 | The payer is added t o a bill o n screen 3 but the p ayer must already ex ist. | |
| 5477 | Payers are defined i n Insuranc e Company Entry/Edit . Insuran ce is ente red for a specific p atient in Patient In surance In fo View/Ed it. Once the insura nce policy exists fo r a patien t, it may be added t o a bill a nd the sys tem knows to which i nsurance c ompany the patient’s policy be longs.. | |
| 5478 | Storage: | |
| 5479 | File - Ins urance Com pany (#36) | |
| 5480 | Field – Na me (#.01) | |
| 5481 | Maximum HI PAA length increased to 60. | |
| 5482 | Set NM101 = PR | |
| 5483 | NM102 =2 | |
| 5484 | 7 | |
| 5485 | Claim Fili ng Indicat or (Type o f Payer) | |
| 5486 | 2 A/N | |
| 5487 | 837: 2320 SBR09 | |
| 5488 | Print: N/A | |
| 5489 | Biller Inp ut: N/A | |
| 5490 | VistA look s at the E lectronic Plan Type of the Gro up Insuran ce Plan. | |
| 5491 | If Medicar e and CMS- 1500 = MB | |
| 5492 | If Medicar e and UB04 = MA | |
| 5493 | If Electro nic Plan T ype is bla nk = CI | |
| 5494 | If Electro nic Plan T ype is MX and Plan C ategory co ntains A = MA | |
| 5495 | If Electro nic Plan T ype is MX and Plan C ategory co ntains B = MB | |
| 5496 | If Electro nic Plan T ype is MX and Plan C ategory do es not con tain A or B = CI | |
| 5497 | Storage: | |
| 5498 | File: GROU P INSURANC E PLAN (#3 55.3) | |
| 5499 | File: PLAN CATEGORY (#.14) | |
| 5500 | Field: ELE CTRONIC PL AN TYPE (# .15) | |
| 5501 | Added code s: | |
| 5502 | 17 - Denta l Manageme nt Org, FI - FEP, MA can now b e used for P and I. | |
| 5503 | Removed Co des: | |
| 5504 | 09 - Self Pay, 10 - Central Ce rtificatio n, LI - Li ability. | |
| 5505 | 8 | |
| 5506 | Insurance Type Code | |
| 5507 | 2 A/N | |
| 5508 | 837: (P) 2 320 SBR05 | |
| 5509 | Print: N/A | |
| 5510 | ||
| 5511 | Biller Inp ut: N/A | |
| 5512 | VistA look s at the E lectronic Plan Type of the Gro up Insuran ce Plan. | |
| 5513 | Storage: | |
| 5514 | File: GROU P INSURANC E PLAN (#3 55.3) | |
| 5515 | Field: ELE CTRONIC PL AN TYPE (# .15) | |
| 5516 | Code list change. Us age change d to situa tional | |
| 5517 | 9 | |
| 5518 | Other Paye r Pt Signa ture Sourc e Code | |
| 5519 | 1 A/N | |
| 5520 | 837: (P) 2 320 OI04 | |
| 5521 | Print: N/A | |
| 5522 | Biller Inp ut: N/A | |
| 5523 | Note: Alwa ys B | |
| 5524 | Storage: N /A | |
| 5525 | Only code now in 501 0 P. | |
| 5526 | ||
| 5527 | ||
| 5528 | ||
| 5529 | OI1A - Loo p 2320/233 0B (Other Subscriber and Other Payer Dat a) | |
| 5530 | One or mor e records per Claim Data recor d set | |
| 5531 | (OPTIONAL – Max leng th104 byt es) | |
| 5532 | Piece | |
| 5533 | Descriptio n | |
| 5534 | Max Length Data Type | |
| 5535 | 837/Print Location | |
| 5536 | VistA Inpu t/Storage | |
| 5537 | FSC Proces sing Comme nts | |
| 5538 | 1 | |
| 5539 | RECORD ID = ‘OI1A ’ | |
| 5540 | 4 A | |
| 5541 | ||
| 5542 | ||
| 5543 | ||
| 5544 | 2 | |
| 5545 | Payer Resp onsibility Sequence # Code | |
| 5546 | 1 A | |
| 5547 | 837: 2320 SBR01 | |
| 5548 | Print: N/A | |
| 5549 | Biller Inp ut: Screen 3 Section 1 | |
| 5550 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er is the destinatio n payer or the Other payers | |
| 5551 | Storage: | |
| 5552 | File: BILL /CLAIMS (# 399) | |
| 5553 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 5554 | Codes adde d to indic ate sequen ce out to 11 payers. VA will o nly use Pr imary (P), Secondary (S) ,Tert iary (T) | |
| 5555 | 3 | |
| 5556 | Other Paye r Paid Amt | |
| 5557 | 15 N | |
| 5558 | 2 Decimals | |
| 5559 | 837: 2320 AMT02 | |
| 5560 | Print: | |
| 5561 | CMS 1500 – Box 29 | |
| 5562 | UB04 – FL5 4 | |
| 5563 | Biller Inp ut: N/A | |
| 5564 | Medicare: | |
| 5565 | File: ACCO UNTS RECEI VABLE (#43 0) | |
| 5566 | Filed: TOT AL PAID PR INCIPAL (# 77) | |
| 5567 | Non-Medica re: | |
| 5568 | File: BILL /CLAIM (#3 99) | |
| 5569 | Field: PRI MARY PRIOR PAYMENT ( #218) | |
| 5570 | Field: SEC ONDARY PRI OR PAYMENT (#219) | |
| 5571 | Field: TER TIARY PRIO R PAYMENT (#220) | |
| 5572 | Set AMT01 = D. | |
| 5573 | 4 | |
| 5574 | COB Total non-Covere d Amount | |
| 5575 | 18 N | |
| 5576 | 2 Decimals | |
| 5577 | 837: 2320 AMT02 | |
| 5578 | Print: N/A | |
| 5579 | Biller Inp ut: N/A | |
| 5580 | System ext racts this amount fr om the cla im file. | |
| 5581 | Storage: | |
| 5582 | File: BILL /CLAIM (#3 99) | |
| 5583 | Field: COB NON-COVER ED CHARGE AMOUNT (#2 60) | |
| 5584 | None | |
| 5585 | 5 | |
| 5586 | COB Total non-Covere d Amount Q ualifier | |
| 5587 | 2 A/N | |
| 5588 | 837: 2320 AMT01 | |
| 5589 | Print: N/A | |
| 5590 | Biller Inp ut: N/A | |
| 5591 | When OI4, Piece 12 i s populate d, the sys tem popula tes this w ith A8. | |
| 5592 | Storage: N /A | |
| 5593 | ||
| 5594 | 6 | |
| 5595 | Remaining Patient Li ability Qu alifier | |
| 5596 | 3 A/N | |
| 5597 | 837: 2320 AMT01 | |
| 5598 | Print: N/A | |
| 5599 | Biller Inp ut: N/A | |
| 5600 | Storage: N /A | |
| 5601 | Note: Alwa ys EAF | |
| 5602 | ||
| 5603 | 7 | |
| 5604 | Remaining Patient Li ability | |
| 5605 | 15 N | |
| 5606 | 2 Decimals | |
| 5607 | 837: 2320 AMT02 | |
| 5608 | Print: N/A | |
| 5609 | Biller Inp ut: N/A | |
| 5610 | This is th e sum of t he patient responsib ility amou nts in the EOB files for each payer. | |
| 5611 | Storage: | |
| 5612 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 5613 | Field: PAT IENT RESPO NSIBILITY AMT (#1.02 ) | |
| 5614 | AMT01=EAF Will need to be trac k separate ly for eac h payer | |
| 5615 | 8 | |
| 5616 | Other Paye r Prior Au thorizatio n Qualifie r | |
| 5617 | 20 A/N | |
| 5618 | 837: | |
| 5619 | (I) 2330B REF01 | |
| 5620 | (P) 2330B REF01 | |
| 5621 | Print: N/A | |
| 5622 | Biller Inp ut: N/A | |
| 5623 | Storage: N /A | |
| 5624 | Note: Alwa ys G1 | |
| 5625 | ||
| 5626 | 9 | |
| 5627 | Other Paye r Prior Au th Number | |
| 5628 | 18 A/N | |
| 5629 | 837: | |
| 5630 | (I) 2330B REF02 | |
| 5631 | (P) 2330B REF02 | |
| 5632 | Print: | |
| 5633 | UB04 – FL6 3 by payer | |
| 5634 | ||
| 5635 | Note: Syst em keeps t rack of pa yer sequen ce. | |
| 5636 | Biller Inp ut: Screen 10 Sectio n 1/2 | |
| 5637 | Storage: | |
| 5638 | File: BILL /CLAIM (#3 99) | |
| 5639 | Field: TRE ATMENT AUT HORIZATION CODE (#16 3) | |
| 5640 | Field: SEC ONDARY AUT HORIZATION CODE (#23 0) | |
| 5641 | Field: TER TIARY AUTH ORIZATION CODE (#231 ) | |
| 5642 | ||
| 5643 | ||
| 5644 | OI2 - Loop 2330A (Ot her Payer Subscriber Data) [SE Q 110] | |
| 5645 | One record per 2320 record | |
| 5646 | (OPTIONAL – Max leng th 256 byt es) | |
| 5647 | Piece | |
| 5648 | Descriptio n | |
| 5649 | Max Length Data Type | |
| 5650 | 837/Print Location | |
| 5651 | VistA Inpu t/Storage | |
| 5652 | FSC Proces sing Comme nts | |
| 5653 | 1 | |
| 5654 | RECORD ID = ‘OI2 ’ | |
| 5655 | 4 A | |
| 5656 | ||
| 5657 | ||
| 5658 | ||
| 5659 | 2 | |
| 5660 | Payer Resp onsibility Sequence # Code | |
| 5661 | 1 A | |
| 5662 | 837: 2320 SBR01 | |
| 5663 | Print: N/A | |
| 5664 | Biller Inp ut: Screen 3 Section 1 | |
| 5665 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 5666 | Storage: | |
| 5667 | File: BILL /CLAIMS (# 399) | |
| 5668 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 5669 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 5670 | 3 | |
| 5671 | Other Subs criber Pri mary ID | |
| 5672 | 80 A/N | |
| 5673 | 837: 2330A NM109 | |
| 5674 | Print: | |
| 5675 | UB04 – FL6 0 | |
| 5676 | Biller Inp ut: N/A | |
| 5677 | Screen 3 S ection 1 | |
| 5678 | The biller can add t he patient ’s insuran ce policy to the bil l on Scree n 3 Sectio n 1. The Subscriber informati on is main tained in Patient In surance In fo View/Ed itAdd Poli cy or Poli cy View/Ed itSubscrib er Updates | |
| 5679 | Storage: | |
| 5680 | File: PATI ENT (#2) | |
| 5681 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 5682 | Field: SUB SCRIBER ID (#11) | |
| 5683 | Set NM108 = MI | |
| 5684 | 4 | |
| 5685 | Other Subs criber Las t Name | |
| 5686 | 60 A/N | |
| 5687 | 837: 2330A NM103 | |
| 5688 | Print: | |
| 5689 | CMS 1500 – Box 9 | |
| 5690 | UB04 – FL5 8 | |
| 5691 | Biller Inp ut: N/A | |
| 5692 | Screen 3 S ection 1 | |
| 5693 | The biller can add t he patient ’s insuran ce policy to the bil l on Scree n 3 Sectio n 1. The Subscriber informati on is main tained in Patient In surance In fo View/Ed itAdd Poli cy or Poli cy View/Ed itSubscrib er Updates | |
| 5694 | Storage: | |
| 5695 | File: PATI ENT (#2) | |
| 5696 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 5697 | Field: NAM E OF INSUR ED (#17) | |
| 5698 | Set NM101 = IL | |
| 5699 | NM102 = 1 | |
| 5700 | Maximum HI PAA length increased to 60. | |
| 5701 | 5 | |
| 5702 | Other Subs criber Fir st Name | |
| 5703 | 35 A/N | |
| 5704 | 837: 2330A NM104 | |
| 5705 | Print: | |
| 5706 | CMS 1500 – Box 9 | |
| 5707 | UB04 – FL 58 | |
| 5708 | Biller Inp ut: N/A | |
| 5709 | Screen 3 S ection 1 | |
| 5710 | Storage: | |
| 5711 | File: PATI ENT (#2) | |
| 5712 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 5713 | Field: NAM E OF INSUR ED (#17) | |
| 5714 | Maximum HI PAA length increased to 35. | |
| 5715 | ||
| 5716 | 6 | |
| 5717 | Other Subs criber Mid dle Name | |
| 5718 | 25 A/N | |
| 5719 | 837: 2330A NM105 | |
| 5720 | Print: | |
| 5721 | CMS 1500 – Box 9 | |
| 5722 | UB04 – FL5 8 | |
| 5723 | Biller Inp ut: N/A | |
| 5724 | Screen 3 S ection 1 | |
| 5725 | Storage: | |
| 5726 | File: PATI ENT (#2) | |
| 5727 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 5728 | Field: NAM E OF INSUR ED (#17) | |
| 5729 | ||
| 5730 | 7 | |
| 5731 | Other Subs criber Emp loyer Name | |
| 5732 | 35 A/N | |
| 5733 | 837: 2330I NM103 | |
| 5734 | Print: | |
| 5735 | UB04 - FL6 5 | |
| 5736 | Biller Inp ut: N/A | |
| 5737 | The subscr iber’s emp loyment in formation is added v ia Patient Insurance Info Add/ EditAdd Po licy or Po licy Edit/ ViewEmploy er Info | |
| 5738 | File: PATI ENT (#2) | |
| 5739 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 5740 | Field: SUB SCRIBER”S EMPLOYER N AME (#2.01 5) | |
| 5741 | Non-HIPAA Field | |
| 5742 | HCCH print ing requir ements | |
| 5743 | Set NM101 = 84 | |
| 5744 | NM102 = 1 | |
| 5745 | 8 | |
| 5746 | BLANK | |
| 5747 | 1 | |
| 5748 | ||
| 5749 | ||
| 5750 | ||
| 5751 | 9 | |
| 5752 | BLANK | |
| 5753 | 1 | |
| 5754 | ||
| 5755 | ||
| 5756 | ||
| 5757 | 10 | |
| 5758 | BLANK | |
| 5759 | 1 | |
| 5760 | ||
| 5761 | ||
| 5762 | ||
| 5763 | 11 | |
| 5764 | Other Subs criber Pri mary ID Qu alifier | |
| 5765 | 3 A/N | |
| 5766 | 837: 2330A NM108 | |
| 5767 | Print: N/A | |
| 5768 | ||
| 5769 | Biller Inp ut: N/A | |
| 5770 | Screen 3 S ection 1 | |
| 5771 | The biller can add t he patient ’s insuran ce policy to the bil l on Scree n 3 Sectio n 1. The Subscriber informati on is main tained in Patient In surance In fo View/Ed itAdd Poli cy or Poli cy View/Ed itSubscrib er Updates | |
| 5772 | Storage: N /A | |
| 5773 | Note: Alwa ys MI. | |
| 5774 | ||
| 5775 | OI4 - Loop 2330B (Ot her Payer Data) [SEQ 112] | |
| 5776 | One record per 2320 record | |
| 5777 | (OPTIONAL – Max leng th 208 byt es) | |
| 5778 | Piece | |
| 5779 | Descriptio n | |
| 5780 | Max Length Data Type | |
| 5781 | 837/Print Location | |
| 5782 | VistA Inpu t/Storage | |
| 5783 | FSC Proces sing Comme nts | |
| 5784 | 1 | |
| 5785 | RECORD ID = ‘OI4 ’ | |
| 5786 | 4 A | |
| 5787 | ||
| 5788 | ||
| 5789 | ||
| 5790 | 2 | |
| 5791 | Payer Resp onsibility Sequence # Code | |
| 5792 | 1 A | |
| 5793 | 837: N/A | |
| 5794 | Print: N/A | |
| 5795 | Biller Inp ut: Screen 3 Section 1 | |
| 5796 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers . | |
| 5797 | Storage: | |
| 5798 | File: BILL /CLAIMS (# 399) | |
| 5799 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 5800 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance.. | |
| 5801 | 3 | |
| 5802 | Other Paye r Address Line 1 | |
| 5803 | 55 A/N | |
| 5804 | 837: 2330B N301 | |
| 5805 | Print: N/A | |
| 5806 | Biller Inp ut: Scree n 3 Sectio n 3 | |
| 5807 | The payer address wi ll be pull ed automat ically fro m the Insu rance Comp any File b ut a user may overri de the def ault answe r. There are addres ses for Ma iling/Inpt /Outpt/RX/ Inquiry an d Appeals claims. T he claim t ype and/or the avail ability of the diffe rent addre sses will affect the default v alue. | |
| 5808 | Storage: | |
| 5809 | File - Ins urance Com pany (#36) | |
| 5810 | Field – Ad dress Line 1 (#.111, .121, .14 1, .151, . 161, .181) | |
| 5811 | Added to 8 37P | |
| 5812 | 4 | |
| 5813 | Other Paye r Address Line 2 | |
| 5814 | 55 A/N | |
| 5815 | 837: 2330B N302 | |
| 5816 | Print: N/A | |
| 5817 | Biller Inp ut: Scree n 3 Sectio n 3 | |
| 5818 | Storage: | |
| 5819 | File - Ins urance Com pany (#36) | |
| 5820 | Field – Ci ty (#.112, .122, .14 2, .152, . 162, .182) | |
| 5821 | Added to 8 37P | |
| 5822 | 5 | |
| 5823 | Other Paye r City Nam e | |
| 5824 | 30 A/N | |
| 5825 | 837: 2330B N401 | |
| 5826 | Print: N/A | |
| 5827 | ||
| 5828 | Biller Inp ut: Scree n 3 Sectio n 3 | |
| 5829 | Storage: | |
| 5830 | File - Ins urance Com pany (#36) | |
| 5831 | Field – CI TY (#.114, .124, .14 4, .154, . 164, .184) | |
| 5832 | Added to 8 37P | |
| 5833 | 6 | |
| 5834 | Other Paye r State Co de | |
| 5835 | 2 A | |
| 5836 | 837: 2330B N402 | |
| 5837 | Print: N/A | |
| 5838 | Biller Inp ut: Scree n 3 Sectio n 3 | |
| 5839 | Storage: | |
| 5840 | File - Ins urance Com pany (#36) | |
| 5841 | Field – ST ATE (#.115 , .125, .1 45, .155, .165, .185 ) | |
| 5842 | Added to 8 37P Requir ed when in US or ter ritories. | |
| 5843 | 7 | |
| 5844 | Other Paye r Zip Code | |
| 5845 | 15 A/N | |
| 5846 | 837: 2330B N403 | |
| 5847 | Print: N/A | |
| 5848 | Biller Inp ut: Scree n 3 Sectio n 3 | |
| 5849 | Storage: | |
| 5850 | File - Ins urance Com pany (#36) | |
| 5851 | Field – ZI P (#.116, .126, .146 , .156, .1 66, .186) | |
| 5852 | Added to 8 37P. Requ ired when in US or t erritories . | |
| 5853 | 8 | |
| 5854 | Other Paye r Check Qu alifier | |
| 5855 | 3 N | |
| 5856 | 837: 2330B DTP01 | |
| 5857 | Print: N/A | |
| 5858 | Biller Inp ut: N/A | |
| 5859 | Storage: N /A | |
| 5860 | Note: Alwa ys 573 | |
| 5861 | ||
| 5862 | 9 | |
| 5863 | Other Paye r Check Da te | |
| 5864 | 8 N CCYYMM DD | |
| 5865 | 837: 2330B DTP03 | |
| 5866 | Print: N/A | |
| 5867 | Biller Inp ut: N/A | |
| 5868 | Storage: | |
| 5869 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 5870 | Field: EOB PAID DATE (#.06) | |
| 5871 | DTP02 = D8 | |
| 5872 | 10 | |
| 5873 | Other Paye r Claim St atus | |
| 5874 | 2 A | |
| 5875 | 837: (I) 2 300 REF02 | |
| 5876 | Print: N/A | |
| 5877 | ||
| 5878 | Biller Inp ut: N/A | |
| 5879 | Storage: | |
| 5880 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 5881 | Field: CLA IM STATUS (#.13) | |
| 5882 | Non HIPAA | |
| 5883 | HCCH print requireme nt | |
| 5884 | Set REF01 = SU Equal to the CL P02 on the 835 | |
| 5885 | 11 | |
| 5886 | Other Paye r Referral Number Qu alifier | |
| 5887 | 2 A/N | |
| 5888 | 837: | |
| 5889 | (I) 2330B REF01 | |
| 5890 | (P) 2330B REF01 | |
| 5891 | Print: N/A | |
| 5892 | Biller Inp ut: N/A | |
| 5893 | Storage: N /A | |
| 5894 | Note: Alwa ys 9F | |
| 5895 | ||
| 5896 | 12 | |
| 5897 | Other Paye r Referral Number | |
| 5898 | 20 A/N | |
| 5899 | 837: | |
| 5900 | (I) 2330B REF02 | |
| 5901 | (P) 2330B REF02 | |
| 5902 | Print: N/A | |
| 5903 | Biller Inp ut: Screen 10 Sectio n ½ | |
| 5904 | There can be a Prima ry, Second ary and Te rtiary Ref erral Numb er. The s ystem will automatic ally keep track of t he current Payer seq uence and which paye r(s) is th e destinat ion payer or the Oth er payers. | |
| 5905 | Storage: B ILL/CLAIM (#399) | |
| 5906 | Field: PRI MARY REFER RAL NUMBER (#253) | |
| 5907 | Field: SEC ONDARY REF ERRAL NUMB ER (#254) | |
| 5908 | Field: PRI MARY REFER RAL NUMBER (#255) | |
| 5909 | ||
| 5910 | ||
| 5911 | OI5 - Loop 2330A (Ot her Payer Subscriber Data) [SE Q 113] | |
| 5912 | One record per 2320 record | |
| 5913 | (OPTIONAL – Max leng th 228 byt es) | |
| 5914 | Piece | |
| 5915 | Descriptio n | |
| 5916 | Max Length Data Type | |
| 5917 | 837/Print Location | |
| 5918 | VistA Inpu t/Storage | |
| 5919 | FSC Proces sing Comme nts | |
| 5920 | 1 | |
| 5921 | RECORD ID = ‘OI5 ’ | |
| 5922 | 4 A | |
| 5923 | ||
| 5924 | ||
| 5925 | ||
| 5926 | 2 | |
| 5927 | Payer Resp onsibility Sequence # Code | |
| 5928 | 1 A | |
| 5929 | 837: N/A | |
| 5930 | Print: N/A | |
| 5931 | Biller Inp ut: Screen 3 Section 1 | |
| 5932 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 5933 | Storage: | |
| 5934 | File: BILL /CLAIMS (# 399) | |
| 5935 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 5936 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance.. | |
| 5937 | 3 | |
| 5938 | Other Subs criber Nam e Suffix | |
| 5939 | 10 A/N | |
| 5940 | 837: 2330A NM107 | |
| 5941 | Print: | |
| 5942 | UB04 – FL5 8 | |
| 5943 | Biller Inp ut: N/A | |
| 5944 | Screen 3 S ection 1 | |
| 5945 | Storage: | |
| 5946 | File: PATI ENT (#1) | |
| 5947 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 5948 | Field: NAM E OF INSUR ED (#17) | |
| 5949 | ||
| 5950 | 4 | |
| 5951 | Other Subs criber Add ress 1 | |
| 5952 | 55 A/N | |
| 5953 | 837: 2330A N301 | |
| 5954 | Print: N/A | |
| 5955 | Biller Inp ut: N/A | |
| 5956 | Screen 3 S ection 1 | |
| 5957 | Storage: | |
| 5958 | File: PATI ENT (#2) | |
| 5959 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 5960 | Field: INS URED’S STR EET 1 (#3. 06) | |
| 5961 | ||
| 5962 | 5 | |
| 5963 | Other Subs criber Add ress 2 | |
| 5964 | 55 A/N | |
| 5965 | 837: 2330A N302 | |
| 5966 | Print: N/A | |
| 5967 | Biller Inp ut: N/A | |
| 5968 | Screen 3 S ection 1 | |
| 5969 | Storage: | |
| 5970 | File: PATI ENT (#2) | |
| 5971 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 5972 | Field: INS URED’S STR EET 2 (#3. 07) | |
| 5973 | ||
| 5974 | 6 | |
| 5975 | Other Subs criber Cit y Name | |
| 5976 | 30 A/N | |
| 5977 | 837: 2330A N401 | |
| 5978 | Print: N/A | |
| 5979 | Biller Inp ut: N/A | |
| 5980 | Screen 3 S ection 1 | |
| 5981 | Storage: | |
| 5982 | File: PATI ENT (#2) | |
| 5983 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 5984 | Field: INS URED’S CIT Y (#3.08) | |
| 5985 | 837P usage changed t o required | |
| 5986 | 7 | |
| 5987 | Other Subs criber Sta te Code | |
| 5988 | 2 A | |
| 5989 | 837: 2330A N402 | |
| 5990 | Print: N/A | |
| 5991 | Biller Inp ut: N/A | |
| 5992 | Screen 3 S ection 1 | |
| 5993 | Storage: | |
| 5994 | File: PATI ENT (#2) | |
| 5995 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 5996 | Field: INS URED’S STA TE (#3.09) | |
| 5997 | Required w hen in US or territo ries. | |
| 5998 | 8 | |
| 5999 | Other Subs criber ZIP Code | |
| 6000 | 10 A/N | |
| 6001 | 837: 2330A N403 | |
| 6002 | Print: N/A | |
| 6003 | Biller Inp ut: N/A | |
| 6004 | Screen 3 S ection 1 | |
| 6005 | Storage: | |
| 6006 | File: PATI ENT (#2) | |
| 6007 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 6008 | Field: INS URED’S ZIP (#3.1) | |
| 6009 | Required w hen in US or territo ries. | |
| 6010 | 9 | |
| 6011 | Other Subs criber Sec ID Qualif ier(1) | |
| 6012 | 2 A/N | |
| 6013 | 837: 2330A REF01 | |
| 6014 | Print: N/A | |
| 6015 | Biller Inp ut: N/A | |
| 6016 | Screen 3 S ection 1 | |
| 6017 | The biller can add t he patient ’s insuran ce policy to the bil l on Scree n 3 Sectio n 1. The Subscriber informati on is main tained in Patient In surance In fo View/Ed itAdd Poli cy or Poli cy View/Ed itSubscrib er Updates | |
| 6018 | Storage: | |
| 6019 | File: PATI ENT (#2) | |
| 6020 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 6021 | Field: SUB SCRIBER’s SEC QUALIF IER(1) ID (#5.02) | |
| 6022 | ||
| 6023 | 10 | |
| 6024 | Other Subs criber Sec ID(1) | |
| 6025 | 50 A/N | |
| 6026 | 837: 2330A REF02 | |
| 6027 | Print: N/A | |
| 6028 | Biller Inp ut: N/A | |
| 6029 | Screen 3 S ection 1 | |
| 6030 | The biller can add t he patient ’s insuran ce policy to the bil l on Scree n 3 Sectio n 1. The Subscriber informati on is main tained in Patient In surance In fo View/Ed itAdd Poli cy or Poli cy View/Ed itSubscrib er Updates | |
| 6031 | Storage: | |
| 6032 | File: PATI ENT (#2) | |
| 6033 | Subfile: I NSURANCE T YPE (#.312 1) | |
| 6034 | Field: SUB SCRIBER’S SEC ID(1) (#5.03) | |
| 6035 | None | |
| 6036 | ||
| 6037 | OI6 - Loop 2330B (Ot her Payer ID Data) [ SEQ 114] | |
| 6038 | (OPTIONAL – Max leng th 145 byt es) | |
| 6039 | Piece | |
| 6040 | Descriptio n | |
| 6041 | Max Length Data Type | |
| 6042 | 837/Print Location | |
| 6043 | VistA Inpu t/Storage | |
| 6044 | FSC Proces sing Comme nts | |
| 6045 | 1 | |
| 6046 | RECORD ID = ‘OI6 ’ | |
| 6047 | 4 A | |
| 6048 | ||
| 6049 | ||
| 6050 | ||
| 6051 | 2 | |
| 6052 | Payer Resp onsibility Sequence # Code | |
| 6053 | 1 A | |
| 6054 | 837: N/A | |
| 6055 | Print: N/A | |
| 6056 | Biller Inp ut: Screen 3 Section 1 | |
| 6057 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 6058 | Storage: | |
| 6059 | File: BILL /CLAIMS (# 399) | |
| 6060 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 6061 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance.. | |
| 6062 | 3 | |
| 6063 | Other Paye r Primary ID Qualifi er | |
| 6064 | 3 A/N | |
| 6065 | 837: 2330B NM108 | |
| 6066 | Print: N/A | |
| 6067 | Biller Inp ut: N/A | |
| 6068 | Storage: N /A | |
| 6069 | ||
| 6070 | 4 | |
| 6071 | Other Paye r Primary ID | |
| 6072 | 30 A/N | |
| 6073 | 837: 2330B NM109 | |
| 6074 | Print: | |
| 6075 | UB04 – FL5 1 by payer | |
| 6076 | ||
| 6077 | Note: This is the le gacy Payer ID. **It will only print if t here is no HPID** | |
| 6078 | ||
| 6079 | Biller Inp ut: N/A | |
| 6080 | Screen 3 S ection 3 | |
| 6081 | The Payer IDs are au tomaticall y entered on a bill when the u ser adds t he insuran ce to the claim. Pa yer IDs ar e enter in Insurance Company E ntry/Edit Billing/ED I Param | |
| 6082 | Storage: | |
| 6083 | File: INSU RANCE COMP ANY (#36) | |
| 6084 | Field: EDI ID NUMBER – PROF (# 3.02) | |
| 6085 | Field: EDI ID NUMBER – INST (# 3.04) | |
| 6086 | ||
| 6087 | 5 | |
| 6088 | Other Paye r Sec ID Q ualifier ( 1) | |
| 6089 | 3 A/N | |
| 6090 | 837: 2330B REF01 | |
| 6091 | Print: N/A | |
| 6092 | Biller Inp ut: N/A | |
| 6093 | Screen 3 S ection 3 | |
| 6094 | Payer IDs are automa tically en tered on a bill when the user adds the i nsurance t o the clai m. Payer IDs are en ter in Ins urance Com pany Entry /EditBilli ng/EDI Par am | |
| 6095 | Storage: | |
| 6096 | File: INSU RANCE COMP ANY (#36) | |
| 6097 | Field: EDI INST SECO NDARY ID Q UAL (1) (# 6.01) | |
| 6098 | Field: EDI PROF SECO NDARY ID Q UAL (1) (# 6.05) | |
| 6099 | Code list includes 2 U, EI, FY and NF. | |
| 6100 | TJ and F8 have been removed. | |
| 6101 | 6 | |
| 6102 | Other Paye r Sec ID ( 1) | |
| 6103 | 30 A/N | |
| 6104 | 837: 2330B REF02 | |
| 6105 | Print: N/A | |
| 6106 | Biller Inp ut: N/A | |
| 6107 | Screen 3 S ection 3 | |
| 6108 | Storage: | |
| 6109 | File: INSU RANCE COMP ANY (#36) | |
| 6110 | Field: EDI INST SECO NDARY ID ( 1) (#6.02) | |
| 6111 | Field: EDI PROF SECO NDARY ID ( 1) (#6.06) | |
| 6112 | ||
| 6113 | 7 | |
| 6114 | Other Paye r Sec ID Q ualifier ( 2) | |
| 6115 | 3 A/N | |
| 6116 | 837: 2330B REF01 | |
| 6117 | Print: N/A | |
| 6118 | Note: This will not be used if the ICN/D CN number in COB1-7 exists. | |
| 6119 | Biller Inp ut: N/A | |
| 6120 | Screen 3 S ection 3 | |
| 6121 | Storage: | |
| 6122 | File: INSU RANCE COMP ANY (#36) | |
| 6123 | Field: EDI INST SECO NDARY ID Q UAL (2) (# 6.03) | |
| 6124 | Field: EDI PROF SECO NDARY ID Q UAL (2) (# 6.07) | |
| 6125 | Code Set C hange: | |
| 6126 | Allowed va lues are 2 U, EI, FY and NF. | |
| 6127 | TJ has bee n removed. | |
| 6128 | 8 | |
| 6129 | Other Paye r Sec ID ( 2) | |
| 6130 | 30 A/N | |
| 6131 | 837: 2330B REF02 | |
| 6132 | Print: N/A | |
| 6133 | Note: This will not be used i f the ICN/ DCN number in COB1-7 exists. | |
| 6134 | Biller Inp ut: N/A | |
| 6135 | Screen 3 S ection 3 | |
| 6136 | Storage: | |
| 6137 | File: INSU RANCE COMP ANY (#36) | |
| 6138 | Field: EDI INST SECO NDARY ID ( 2) (#6.04) | |
| 6139 | Field: EDI PROF SECO NDARY ID ( 2) (#6.08) | |
| 6140 | ||
| 6141 | 9 | |
| 6142 | Other Paye r ID Quali fier | |
| 6143 | 2 A | |
| 6144 | 837: 2330B B NM108 | |
| 6145 | Print: N/A | |
| 6146 | Biller Inp ut: N/A | |
| 6147 | Storage: N /A | |
| 6148 | Note: Alwa ys XV | |
| 6149 | ||
| 6150 | 10 | |
| 6151 | Other Paye r Primary ID (HPID) | |
| 6152 | 30 A/N | |
| 6153 | 837: 2330B B NM109 | |
| 6154 | Print: | |
| 6155 | UB04 – FL5 1 by payer | |
| 6156 | Biller Inp ut: N/A | |
| 6157 | Screen 3 S ection 3 | |
| 6158 | Payer IDs are automa tically en ter on a b ill when t he user ad ds the ins urance to the claim. Payer ID s are ente r in Insur ance Compa ny Entry/E ditBilling /EDI Param | |
| 6159 | Storage: | |
| 6160 | File: INSU RANCE COMP ANY (#36) | |
| 6161 | Subfile: H PID/OEID ( #.08) | |
| 6162 | Field: HPI D/OEID (#. 01) | |
| 6163 | ||
| 6164 | ||
| 6165 | COB1 - Loo p 2320 (Cl aim Level COB Amount s) [SEQ 11 5] | |
| 6166 | Maximum on e record p er OI1 rec ord | |
| 6167 | (OPTIONAL – Max leng th 65 byte s) | |
| 6168 | Piece | |
| 6169 | Descriptio n | |
| 6170 | Max Length Data Type | |
| 6171 | 837/Print Location | |
| 6172 | VistA Inpu t/Storage | |
| 6173 | FSC Proces sing Comme nts | |
| 6174 | 1 | |
| 6175 | RECORD ID = ‘COB1’ | |
| 6176 | 4 A | |
| 6177 | ||
| 6178 | ||
| 6179 | ||
| 6180 | 2 | |
| 6181 | Payer Resp onsibility Sequence # Code | |
| 6182 | 1 A | |
| 6183 | 837: N/A | |
| 6184 | Print: N/A | |
| 6185 | Biller Inp ut: Screen 3 Section 1 | |
| 6186 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 6187 | Storage: | |
| 6188 | File: BILL /CLAIMS (# 399) | |
| 6189 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 6190 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 6191 | 3 | |
| 6192 | BLANK | |
| 6193 | 1 | |
| 6194 | ||
| 6195 | ||
| 6196 | Element m oved to OI 1 piece 20 . | |
| 6197 | 4 | |
| 6198 | BLANK | |
| 6199 | 1 | |
| 6200 | ||
| 6201 | ||
| 6202 | ||
| 6203 | 5 | |
| 6204 | BLANK | |
| 6205 | 1 | |
| 6206 | ||
| 6207 | ||
| 6208 | ||
| 6209 | 6 | |
| 6210 | BLANK | |
| 6211 | 1 | |
| 6212 | ||
| 6213 | ||
| 6214 | ||
| 6215 | 7 | |
| 6216 | Other Paye r Claim Co ntrol Numb er | |
| 6217 | 50 A/N | |
| 6218 | 837: | |
| 6219 | (I) 2330B REF02 | |
| 6220 | (P) 2320B REF02 | |
| 6221 | Print: | |
| 6222 | UB04 – FL6 4 by payer | |
| 6223 | ||
| 6224 | Biller Inp ut: Screen 10 Sectio n 1/2 | |
| 6225 | On a secon dary or te rtiary cla im, the sy stem will automatica lly popula te the ICN from the electronic EOB. User s may manu ally enter one or mo re ICNs if necessary . | |
| 6226 | Storage: | |
| 6227 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6228 | Field: ICN (#.14) | |
| 6229 | Set REF01 = F8 | |
| 6230 | Moved from OI1, Piec e 10 | |
| 6231 | Note: Do n ot delete this recor d without concurrenc e from FSC . FSC use s this rec ord to ide ntify the end of the OI segmen ts. | |
| 6232 | ||
| 6233 | MOA1 - Loo p 2320 (Me dicare Out patient Ad judication COB Data) [SEQ 120] | |
| 6234 | Maximum on e record p er OI1 rec ord | |
| 6235 | (OPTIONAL – Max leng th 138 byt es) | |
| 6236 | Piece | |
| 6237 | Descriptio n | |
| 6238 | Max Length | |
| 6239 | Data Type | |
| 6240 | 837/Print Location | |
| 6241 | VistA Inpu t/Storage | |
| 6242 | FSC proces sing Comme nts | |
| 6243 | 1 | |
| 6244 | RECORD ID = ‘MOA1’ | |
| 6245 | 4 A | |
| 6246 | ||
| 6247 | ||
| 6248 | ||
| 6249 | 2 | |
| 6250 | Payer Resp onsibility Sequence # Code | |
| 6251 | 1 A | |
| 6252 | 837: N/A | |
| 6253 | Print: N/A | |
| 6254 | Biller Inp ut: Screen 3 Section 1 | |
| 6255 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 6256 | Storage: | |
| 6257 | File: BILL /CLAIMS (# 399) | |
| 6258 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 6259 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 6260 | 3 | |
| 6261 | Outpatient Reimburse ment Rate | |
| 6262 | 3 N | |
| 6263 | 837: 2320 MOA01 | |
| 6264 | Print: N/A | |
| 6265 | Biller Inp ut: N/A | |
| 6266 | Storage: | |
| 6267 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6268 | Field: M-C ARE OUTP R EIMBURS. R ATE (#3.01 ) | |
| 6269 | ||
| 6270 | 4 | |
| 6271 | HCPCS Paya ble Amt | |
| 6272 | 15 N | |
| 6273 | 2 Decimals | |
| 6274 | 837: 2320 MOA02 | |
| 6275 | Print: N/A | |
| 6276 | ||
| 6277 | Biller Inp ut: N/A | |
| 6278 | Storage: | |
| 6279 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6280 | Field: M-C ARE OUTP H CPCS PAYMN T AMT (#3. 02) | |
| 6281 | ||
| 6282 | 5 | |
| 6283 | REMARKS CO DE (1) | |
| 6284 | 15 A/N | |
| 6285 | 837: 2320 MOA03 | |
| 6286 | Print: N/A | |
| 6287 | Biller Inp ut: N/A | |
| 6288 | Storage: | |
| 6289 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6290 | Field: M-C ARE OUTP R EMARKS COD E - 1 (#3. 03) | |
| 6291 | Maximum HI PAA length increased to 50. | |
| 6292 | 6 | |
| 6293 | REMARKS CO DE (2) | |
| 6294 | 15 A/N | |
| 6295 | 837: 2320 MOA04 | |
| 6296 | Print: N/A | |
| 6297 | Biller Inp ut: N/A | |
| 6298 | Storage: | |
| 6299 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6300 | Field: M-C ARE OUTP R EMARKS COD E - 2 (#3. 04) | |
| 6301 | Maximum HI PAA length increased to 50. | |
| 6302 | 7 | |
| 6303 | REMARKS CO DE (3) | |
| 6304 | 15 A/N | |
| 6305 | 837: 2320 MOA05 | |
| 6306 | Print: N/A | |
| 6307 | Biller Inp ut: N/A | |
| 6308 | Storage: | |
| 6309 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6310 | Field: M-C ARE OUTP R EMARKS COD E - 3 (#3. 05) | |
| 6311 | Maximum HI PAA length increased to 50. | |
| 6312 | 8 | |
| 6313 | REMARKS CO DE (4) | |
| 6314 | 15 A/N | |
| 6315 | 837: 2320 MOA06 | |
| 6316 | Print: N/A | |
| 6317 | Biller Inp ut: N/A | |
| 6318 | Storage: | |
| 6319 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6320 | Field: M-C ARE OUTP R EMARKS COD E - 4 (#3. 06) | |
| 6321 | Maximum HI PAA length increased to 50. | |
| 6322 | 9 | |
| 6323 | REMARKS CO DE (5) | |
| 6324 | 15 A/N | |
| 6325 | 837: 2320 MOA07 | |
| 6326 | Print: N/A | |
| 6327 | Biller Inp ut: N/A | |
| 6328 | Storage: | |
| 6329 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6330 | Field: M-C ARE OUTP R EMARKS COD E - 5 (#3. 07) | |
| 6331 | Maximum HI PAA length increased to 50. | |
| 6332 | 10 | |
| 6333 | ESRD Payme nt Amt | |
| 6334 | 15 N | |
| 6335 | 2 Decimals | |
| 6336 | 837: 2320 MOA08 | |
| 6337 | Print: N/A | |
| 6338 | Biller Inp ut: N/A | |
| 6339 | Storage: | |
| 6340 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6341 | Field: M-C ARE ESRD P AID AMT (# 3.08) | |
| 6342 | ||
| 6343 | 11 | |
| 6344 | Non-payabl e Prof Com ponent Bil led Amt | |
| 6345 | 15 N | |
| 6346 | 2 Decimals | |
| 6347 | 837: 2320 MOA09 | |
| 6348 | Print: N/A | |
| 6349 | Biller Inp ut: N/A | |
| 6350 | Storage: | |
| 6351 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6352 | Field: M-N ON-PAYABLE PROF COMP (#3.09) | |
| 6353 | ||
| 6354 | ||
| 6355 | MIA1 - Loo p 2320 (Me dicare Inp atient Adj udication COB Data) [SEQ 125] | |
| 6356 | Maximum on e record p er OI1 rec ord | |
| 6357 | (OPTIONAL – Max leng th 150 byt es) | |
| 6358 | Piece | |
| 6359 | Descriptio n | |
| 6360 | Max Length Data Type | |
| 6361 | 837/Print Location | |
| 6362 | VistA Inpu t/Storage | |
| 6363 | FSC Proces sing Comme nts | |
| 6364 | 1 | |
| 6365 | RECORD ID = ‘MIA1’ | |
| 6366 | 4 A | |
| 6367 | ||
| 6368 | ||
| 6369 | ||
| 6370 | 2 | |
| 6371 | Payer Resp onsibility Sequence # Code | |
| 6372 | 1 A | |
| 6373 | ||
| 6374 | Biller Inp ut: Screen 3 Section 1 | |
| 6375 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 6376 | Storage: | |
| 6377 | File: BILL /CLAIMS (# 399) | |
| 6378 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 6379 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 6380 | 3 | |
| 6381 | Covered Da ys or Visi ts Amt | |
| 6382 | 4 N | |
| 6383 | 837: (I) 2 320 MIA01 | |
| 6384 | Print: N/A | |
| 6385 | Biller Inp ut: N/A | |
| 6386 | Storage: | |
| 6387 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6388 | Field: M-C ARE INP CO V. DAYS/VI SIT CT (# 4.01) | |
| 6389 | Usage cha nged to si tuational | |
| 6390 | 4 | |
| 6391 | Claim DRG Amt | |
| 6392 | 15 N | |
| 6393 | 2 Decimals | |
| 6394 | 837: (I) 2 320 MIA04 | |
| 6395 | Print: N/A | |
| 6396 | Biller Inp ut: N/A | |
| 6397 | Storage: | |
| 6398 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6399 | Field: M-C ARE INP CL AIM DRG AM T (#4.03) | |
| 6400 | ||
| 6401 | 5 | |
| 6402 | DRG Used | |
| 6403 | 10 A/N | |
| 6404 | 837: (I)23 00 REF02 ( 2) | |
| 6405 | Print: N/A | |
| 6406 | Biller Inp ut: N/A | |
| 6407 | Storage: | |
| 6408 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6409 | Field: DRG Used (#. 1) | |
| 6410 | Non-HIPAA field | |
| 6411 | HCCH UB04 printing r equirement | |
| 6412 | Set REF01 = ZZ | |
| 6413 | 6 | |
| 6414 | Claim Disp roportiona te Share A mt | |
| 6415 | 15 N | |
| 6416 | 2 Decimals | |
| 6417 | 837: (I) 2 320 MIA06 | |
| 6418 | Print: N/A | |
| 6419 | Biller Inp ut: N/A | |
| 6420 | Storage: | |
| 6421 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6422 | Field: M-C ARE INP DI SPROP. SHA RE AMT (# 4.05) | |
| 6423 | ||
| 6424 | 7 | |
| 6425 | Claim MSP Pass-throu gh Amt | |
| 6426 | 15 N | |
| 6427 | 2 Decimals | |
| 6428 | 837: (I) 2 320 MIA07 | |
| 6429 | Print: N/A | |
| 6430 | Biller Inp ut: N/A | |
| 6431 | Storage: | |
| 6432 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6433 | Field: M-C ARE INP MS P PASS THR U AMT (#4 .06) | |
| 6434 | ||
| 6435 | 8 | |
| 6436 | Claim PPS Capital Am t | |
| 6437 | ||
| 6438 | 15 N | |
| 6439 | 2 Decimals | |
| 6440 | 837: (I) 2 320 MIA08 | |
| 6441 | Print: N/A | |
| 6442 | Biller Inp ut: N/A | |
| 6443 | Storage: | |
| 6444 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6445 | Field: M-C ARE INP PP S CAPITAL AMT (#4. 07) | |
| 6446 | ||
| 6447 | 9 | |
| 6448 | PPS-Capita l FSP DRG Amt | |
| 6449 | 15 N | |
| 6450 | 2 Decimals | |
| 6451 | 837: (I) 2 320 MIA09 | |
| 6452 | Print: N/A | |
| 6453 | Biller Inp ut: N/A | |
| 6454 | Storage: | |
| 6455 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6456 | Field: M-C ARE INP PP S CAP FSP- DRG AMT ( #4.08) | |
| 6457 | ||
| 6458 | 10 | |
| 6459 | PPS-Capita l HSP DRG Amt | |
| 6460 | 15 N | |
| 6461 | 2 Decimals | |
| 6462 | 837: (I) 2 320 MIA10 | |
| 6463 | Print: N/A | |
| 6464 | Biller Inp ut: N/A | |
| 6465 | Storage: | |
| 6466 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6467 | Field: M-C ARE INP PP S CAP HSP- DRG AMT ( #4.09) | |
| 6468 | ||
| 6469 | 11 | |
| 6470 | PPS-Capita l DSH DRG Amt | |
| 6471 | 15 N | |
| 6472 | 2 Decimals | |
| 6473 | 837: (I) 2 320 MIA11 | |
| 6474 | Print: N/A | |
| 6475 | Biller Inp ut: N/A | |
| 6476 | Storage: | |
| 6477 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6478 | Field: M-C ARE INP PP S CAP DSH- DRG AMT ( #4.1) | |
| 6479 | ||
| 6480 | 12 | |
| 6481 | Old Capita l Amt | |
| 6482 | 15 N | |
| 6483 | 2 Decimals | |
| 6484 | 837: (I) 2 320 MA12 | |
| 6485 | Print: N/A | |
| 6486 | Biller Inp ut: N/A | |
| 6487 | Storage: | |
| 6488 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6489 | Field: M-C ARE INP OL D CAPITAL AMT (#4.1 1) | |
| 6490 | ||
| 6491 | MIA2 - Loo p 2320 (Me dicare Inp atient Adj udication COB Data) [SEQ 130] | |
| 6492 | Maximum on e record p er OI1 rec ord | |
| 6493 | (OPTIONAL – Max leng th 167 byt es) | |
| 6494 | Piece | |
| 6495 | Descriptio n | |
| 6496 | Max Length Data Type | |
| 6497 | 837/Print Location | |
| 6498 | VistA Inpu t/Storage | |
| 6499 | FSC Proces sing Comme nts | |
| 6500 | 1 | |
| 6501 | RECORD ID = ‘MIA2’ | |
| 6502 | 4 A | |
| 6503 | ||
| 6504 | ||
| 6505 | ||
| 6506 | 2 | |
| 6507 | Payer Resp onsibility Sequence # Code | |
| 6508 | 1 A | |
| 6509 | ||
| 6510 | Biller Inp ut: Screen 3 Section 1 | |
| 6511 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 6512 | Storage: | |
| 6513 | File: BILL /CLAIMS (# 399) | |
| 6514 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 6515 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 6516 | 3 | |
| 6517 | PPS-Capita l IME Amt | |
| 6518 | 4 N | |
| 6519 | 2 Decimals | |
| 6520 | 837: (I) 2 320 MIA13 | |
| 6521 | Print: N/A | |
| 6522 | Biller Inp ut: N/A | |
| 6523 | Storage: | |
| 6524 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6525 | Field: M-C ARE INP PP S CAPITAL IME AMT ( #4.12) | |
| 6526 | ||
| 6527 | 4 | |
| 6528 | PPS-Operat ing Hospit al Specifi c DRG Amt | |
| 6529 | 15 N | |
| 6530 | 2 Decimals | |
| 6531 | 837: (I) 2 320 MIA14 | |
| 6532 | Print: N/A | |
| 6533 | ||
| 6534 | Biller Inp ut: N/A | |
| 6535 | Storage: | |
| 6536 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6537 | Field: M-C ARE INP PP S OP HOS D RG AMT (# 4.13) | |
| 6538 | ||
| 6539 | 5 | |
| 6540 | Cost Repor t Day Coun t | |
| 6541 | 4 N | |
| 6542 | 837: (I) 2 320 MIA15 | |
| 6543 | Print: N/A | |
| 6544 | Biller Inp ut: N/A | |
| 6545 | Storage: | |
| 6546 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6547 | Field: M-C ARE INP CO ST REPORT DAY CT (#4 .14) | |
| 6548 | ||
| 6549 | 6 | |
| 6550 | PPS-Operat ing Federa l Specific DRG Amt | |
| 6551 | 15 N | |
| 6552 | 2 Decimals | |
| 6553 | 837: (I) 2 320 MIA16 | |
| 6554 | Print: N/A | |
| 6555 | ||
| 6556 | Biller Inp ut: N/A | |
| 6557 | Storage: | |
| 6558 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6559 | Field: M-C ARE INP PP S OP FED D RG AMT (# 4.15) | |
| 6560 | ||
| 6561 | 7 | |
| 6562 | Claim PPS Capital Ou tlier Amt | |
| 6563 | 15 N | |
| 6564 | 2 Decimals | |
| 6565 | 837: (I) 2 320 MIA17 | |
| 6566 | Print: N/A | |
| 6567 | ||
| 6568 | Biller Inp ut: N/A | |
| 6569 | Storage: | |
| 6570 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6571 | Field: M-C ARE INP PP S CAPITAL OUTLIER A MT (#4.16 ) | |
| 6572 | ||
| 6573 | 8 | |
| 6574 | Claim Indi rect Teach ing Amt | |
| 6575 | 15 N | |
| 6576 | 2 Decimals | |
| 6577 | 837: (I) 2 320 MIA18 | |
| 6578 | Print: N/A | |
| 6579 | ||
| 6580 | Biller Inp ut: N/A | |
| 6581 | Storage: | |
| 6582 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6583 | Field: M-C ARE INP IN DIRECT TEA CH AMT (# 4.17) | |
| 6584 | ||
| 6585 | 9 | |
| 6586 | Non-Payabl e Prof Com ponent Amt | |
| 6587 | 15 N | |
| 6588 | 2 Decimals | |
| 6589 | 837: (I) 2 320 MIA19 | |
| 6590 | Print: N/A | |
| 6591 | ||
| 6592 | Biller Inp ut: N/A | |
| 6593 | Storage: | |
| 6594 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6595 | Field: M-C ARE INP NO N-PAY PROF COMP (#4. 18) | |
| 6596 | ||
| 6597 | 10 | |
| 6598 | Claim Paym ent Remark Code (1) | |
| 6599 | 10 A/N | |
| 6600 | 837: (I) 2 320 MIA05 | |
| 6601 | Print: N/A | |
| 6602 | Biller Inp ut: N/A | |
| 6603 | Storage: | |
| 6604 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6605 | Field: M-C ARE INP PY MNT REMARK CODE-1 (# 5.01) | |
| 6606 | Max HIPAA length inc reased to 50. | |
| 6607 | 11 | |
| 6608 | Claim Paym ent Remark Code (2) | |
| 6609 | 10 A/N | |
| 6610 | 837: (I) 2 320 MIA20 | |
| 6611 | Print: N/A | |
| 6612 | Biller Inp ut: N/A | |
| 6613 | Storage: | |
| 6614 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6615 | Field: M-C ARE INP PY MNT REMARK CODE-2 (# 5.02) | |
| 6616 | Max HIPAA length inc reased to 50. | |
| 6617 | 12 | |
| 6618 | Claim Paym ent Remark Code (3) | |
| 6619 | 10 A/N | |
| 6620 | 837: (I) 2 320 MIA21 | |
| 6621 | Print: N/A | |
| 6622 | Biller Inp ut: N/A | |
| 6623 | Storage: | |
| 6624 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6625 | Field: M-C ARE INP PY MNT REMARK CODE-3 (# 5.03) | |
| 6626 | Max HIPAA length inc reased to 50. | |
| 6627 | 13 | |
| 6628 | Claim Paym ent Remark Code (4) | |
| 6629 | 10 A/N | |
| 6630 | 837: (I) 2 320 MIA22 | |
| 6631 | Print: N/A | |
| 6632 | Biller Inp ut: N/A | |
| 6633 | Storage: | |
| 6634 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6635 | Field: M-C ARE INP PY MNT REMARK CODE-4 (# 5.04) | |
| 6636 | Max HIPAA length inc reased to 50. | |
| 6637 | 14 | |
| 6638 | Claim Paym ent Remark Code (5) | |
| 6639 | 10 A/N | |
| 6640 | 837: (I) 2 320 MIA23 | |
| 6641 | Print: N/A | |
| 6642 | Biller Inp ut: N/A | |
| 6643 | Storage: | |
| 6644 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6645 | Field: M-C ARE INP PY MNT REMARK CODE-5 (# 5.05) | |
| 6646 | Max HIPAA length inc reased to 50. | |
| 6647 | 15 | |
| 6648 | PPS-Capita l Exceptio n Amt | |
| 6649 | 15 N | |
| 6650 | 2 Decimals | |
| 6651 | 837: (I) 2 320 MIA24 | |
| 6652 | Print: N/A | |
| 6653 | Biller Inp ut: N/A | |
| 6654 | Storage: | |
| 6655 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6656 | Field: M-C ARE INP CA P EXCEPTIO N AMT (#4. 04) | |
| 6657 | ||
| 6658 | ||
| 6659 | CCAS - Loo p 2320 (CO B Claim Le vel Adjust ments) [SE Q 135] | |
| 6660 | One or mor e records per OI1 re cord | |
| 6661 | (OPTIONAL – Max leng th 183 byt es) | |
| 6662 | Piece | |
| 6663 | Descriptio n | |
| 6664 | Max Length Data Type | |
| 6665 | 837/Print Location | |
| 6666 | VistA Inpu t/Storage | |
| 6667 | FSC Proces sing Comme nts | |
| 6668 | 1 | |
| 6669 | RECORD ID = ‘CCAS’ | |
| 6670 | 4 A | |
| 6671 | ||
| 6672 | ||
| 6673 | ||
| 6674 | 2 | |
| 6675 | Payer Resp onsibility Sequence # Code | |
| 6676 | 1 A | |
| 6677 | 837: N/A | |
| 6678 | Print: N/A | |
| 6679 | Biller Inp ut: Screen 3 Section 1 | |
| 6680 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 6681 | Storage: | |
| 6682 | File: BILL /CLAIMS (# 399) | |
| 6683 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 6684 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 6685 | 3 | |
| 6686 | Adjustment Group Cod e | |
| 6687 | 2 A | |
| 6688 | 837: 2320 CAS01 | |
| 6689 | Print: N/A | |
| 6690 | Biller Inp ut: N/A | |
| 6691 | Storage: | |
| 6692 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6693 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6694 | Subfield: ADJUSTMEN T CATEGORY (GRP COD E) (#.01) | |
| 6695 | ||
| 6696 | 4 | |
| 6697 | Adjustment Reason Co de (1) | |
| 6698 | 5 A/N | |
| 6699 | 837: 2320 CAS02 | |
| 6700 | Print: N/A | |
| 6701 | Biller Inp ut: N/A | |
| 6702 | Storage: | |
| 6703 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6704 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6705 | Subfield: REASON (#1 ) | |
| 6706 | Subfield: REASON COD E (#.01) | |
| 6707 | ||
| 6708 | 5 | |
| 6709 | Adjustment Amt (1) | |
| 6710 | 15 N | |
| 6711 | 2 Decimals | |
| 6712 | 837: 2320 CAS03 | |
| 6713 | Print: N/A | |
| 6714 | Biller Inp ut: N/A | |
| 6715 | Storage: | |
| 6716 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6717 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6718 | Subfield: REASON (#1 ) | |
| 6719 | Subfield: AMOUNT (#. 02) | |
| 6720 | ||
| 6721 | 6 | |
| 6722 | Adjustment Quantity (1) | |
| 6723 | 6 N | |
| 6724 | 837: 2320 CAS04 | |
| 6725 | Print: N/A | |
| 6726 | Biller Inp ut: N/A | |
| 6727 | Storage: | |
| 6728 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6729 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6730 | Subfield: REASON (#1 ) | |
| 6731 | Subfield: QUANTITY ( #.03) | |
| 6732 | ||
| 6733 | 7 | |
| 6734 | Adjustment Reason Co de (2) | |
| 6735 | 5 A/N | |
| 6736 | 837: 2320 CAS05 | |
| 6737 | Print: N/A | |
| 6738 | Biller Inp ut: N/A | |
| 6739 | Storage: | |
| 6740 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6741 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6742 | Subfield: REASON (#1 ) | |
| 6743 | Subfield: REASON COD E (#.01) | |
| 6744 | ||
| 6745 | 8 | |
| 6746 | Adjustment Amt (2) | |
| 6747 | 15 N | |
| 6748 | 2 Decimals | |
| 6749 | 837: 2320 CAS06 | |
| 6750 | Print: N/A | |
| 6751 | Biller Inp ut: N/A | |
| 6752 | Storage: | |
| 6753 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6754 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6755 | Subfield: REASON (#1 ) | |
| 6756 | Subfield: AMOUNT (#. 02) | |
| 6757 | ||
| 6758 | 9 | |
| 6759 | Adjustment Quantity (2) | |
| 6760 | 6 N | |
| 6761 | 837: 2320 CAS07 | |
| 6762 | Print: N/A | |
| 6763 | Biller Inp ut: N/A | |
| 6764 | Storage: | |
| 6765 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6766 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6767 | Subfield: REASON (#1 ) | |
| 6768 | Subfield: QUANTITY ( #.03) | |
| 6769 | ||
| 6770 | 10 | |
| 6771 | Adjustment Reason Co de (3) | |
| 6772 | 5 A/N | |
| 6773 | 837: 2320 CAS08 | |
| 6774 | Print: N/A | |
| 6775 | Biller Inp ut: N/A | |
| 6776 | Storage: | |
| 6777 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6778 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6779 | Subfield: REASON (#1 ) | |
| 6780 | Subfield: REASON COD E (#.01) | |
| 6781 | ||
| 6782 | 11 | |
| 6783 | Adjustment Amt (3) | |
| 6784 | 15 N | |
| 6785 | 2 Decimals | |
| 6786 | 837: 2320 CAS09 | |
| 6787 | Print: N/A | |
| 6788 | Biller Inp ut: N/A | |
| 6789 | Storage: | |
| 6790 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6791 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6792 | Subfield: REASON (#1 ) | |
| 6793 | Subfield: AMOUNT (#. 02) | |
| 6794 | ||
| 6795 | 12 | |
| 6796 | Adjustment Quantity (3) | |
| 6797 | 6 N | |
| 6798 | 837: 2320 CAS10 | |
| 6799 | Print: N/A | |
| 6800 | Biller Inp ut: N/A | |
| 6801 | Storage: | |
| 6802 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6803 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6804 | Subfield: REASON (#1 ) | |
| 6805 | Subfield: QUANTITY ( #.03) | |
| 6806 | ||
| 6807 | 13 | |
| 6808 | Adjustment Reason Co de (4) | |
| 6809 | 5 A/N | |
| 6810 | 837: 2320 CAS11 | |
| 6811 | Print: N/A | |
| 6812 | Biller Inp ut: N/A | |
| 6813 | Storage: | |
| 6814 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6815 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6816 | Subfield: REASON (#1 ) | |
| 6817 | Subfield: REASON COD E (#.01) | |
| 6818 | ||
| 6819 | 14 | |
| 6820 | Adjustment Amt (4) | |
| 6821 | 15 N | |
| 6822 | 2 Decimals | |
| 6823 | 837: 2320 CAS12 | |
| 6824 | Print: N/A | |
| 6825 | Biller Inp ut: N/A | |
| 6826 | Storage: | |
| 6827 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6828 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6829 | Subfield: REASON (#1 ) | |
| 6830 | Subfield: AMOUNT (#. 02) | |
| 6831 | ||
| 6832 | 15 | |
| 6833 | Adjustment Quantity (4) | |
| 6834 | 6 N | |
| 6835 | 837: 2320 CAS13 | |
| 6836 | Print: N/A | |
| 6837 | Biller Inp ut: N/A | |
| 6838 | Storage: | |
| 6839 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6840 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6841 | Subfield: REASON (#1 ) | |
| 6842 | Subfield: QUANTITY ( #.03) | |
| 6843 | ||
| 6844 | 16 | |
| 6845 | Adjustment Reason Co de (5) | |
| 6846 | 5 A/N | |
| 6847 | 837: 2320 CAS14 | |
| 6848 | Print: N/A | |
| 6849 | Biller Inp ut: N/A | |
| 6850 | Storage: | |
| 6851 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6852 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6853 | Subfield: REASON (#1 ) | |
| 6854 | Subfield: REASON COD E (#.01) | |
| 6855 | ||
| 6856 | 17 | |
| 6857 | Adjustment Amt (5) | |
| 6858 | 15 N | |
| 6859 | 2 Decimals | |
| 6860 | 837: 2320 CAS15 | |
| 6861 | Print: N/A | |
| 6862 | Biller Inp ut: N/A | |
| 6863 | Storage: | |
| 6864 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6865 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6866 | Subfield: REASON (#1 ) | |
| 6867 | Subfield: AMOUNT (#. 02) | |
| 6868 | ||
| 6869 | 18 | |
| 6870 | Adjustment Quantity (5) | |
| 6871 | 6 N | |
| 6872 | 837: 2320 CAS16 | |
| 6873 | Print: N/A | |
| 6874 | Biller Inp ut: N/A | |
| 6875 | Storage: | |
| 6876 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6877 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6878 | Subfield: REASON (#1 ) | |
| 6879 | Subfield: QUANTITY ( #.03) | |
| 6880 | ||
| 6881 | 19 | |
| 6882 | Adjustment Reason Co de (6) | |
| 6883 | 5 A/N | |
| 6884 | 837: 2320 CAS17 | |
| 6885 | Print: N/A | |
| 6886 | Biller Inp ut: N/A | |
| 6887 | Storage: | |
| 6888 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6889 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6890 | Subfield: REASON (#1 ) | |
| 6891 | Subfield: REASON COD E (#.01) | |
| 6892 | ||
| 6893 | 20 | |
| 6894 | Adjustment Amt (6) | |
| 6895 | 15 N | |
| 6896 | 2 Decimals | |
| 6897 | 837: 2320 CAS18 | |
| 6898 | Print: N/A | |
| 6899 | Biller Inp ut: N/A | |
| 6900 | Storage: | |
| 6901 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6902 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6903 | Subfield: REASON (#1 ) | |
| 6904 | Subfield: AMOUNT (#. 02) | |
| 6905 | ||
| 6906 | 21 | |
| 6907 | Adjustment Quantity (6) | |
| 6908 | 6 N | |
| 6909 | 837: 2320 CAS19 | |
| 6910 | Print: N/A | |
| 6911 | Biller Inp ut: N/A | |
| 6912 | Storage: | |
| 6913 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 6914 | Subfile: 8 35 CLAIM L EVEL ADJUS TMENTS (#1 0) | |
| 6915 | Subfield: REASON (#1 ) | |
| 6916 | Subfield: QUANTITY ( #.03) | |
| 6917 | ||
| 6918 | ||
| 6919 | ||
| 6920 | OP1 - Loop 2330C/D ( Other Paye r Renderin g Provider Data) [SE Q 170] | |
| 6921 | One record per 2320 record | |
| 6922 | (OPTIONAL – Max leng th 113 byt es) | |
| 6923 | Piece | |
| 6924 | Descriptio n | |
| 6925 | Max Length Data Type | |
| 6926 | 837/Print Location | |
| 6927 | VistA Inpu t/Storage | |
| 6928 | FSC Proces sing Comme nts | |
| 6929 | 1 | |
| 6930 | RECORD ID = ‘OP1 ’ | |
| 6931 | 4 A | |
| 6932 | N/A | |
| 6933 | ||
| 6934 | ||
| 6935 | 2 | |
| 6936 | Payer Resp onsibility Sequence # Code | |
| 6937 | 1 A | |
| 6938 | N/A | |
| 6939 | Biller Inp ut: Screen 3 Section 1 | |
| 6940 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 6941 | Storage: | |
| 6942 | File: BILL /CLAIMS (# 399) | |
| 6943 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 6944 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance.. | |
| 6945 | 3 | |
| 6946 | Other Paye r Renderin g Entity I D | |
| 6947 | ||
| 6948 | 2 A/N | |
| 6949 | 837: | |
| 6950 | (I) 2330G NM101 | |
| 6951 | (P) 2330D NM101 | |
| 6952 | Print: N/A | |
| 6953 | Biller Inp ut: N/A | |
| 6954 | Storage: N /A | |
| 6955 | ||
| 6956 | Note: Alwa ys 82 | |
| 6957 | 837I: Adde d loop. | |
| 6958 | 837P: Loop has chang ed to 2330 D. | |
| 6959 | 4 | |
| 6960 | Other Paye r Renderin g Entity T ype Qualif ier | |
| 6961 | ||
| 6962 | 1 N | |
| 6963 | 837: | |
| 6964 | (I) 2330G NM102 | |
| 6965 | (P) 2330D NM102 | |
| 6966 | Print: N/A | |
| 6967 | Biller Inp ut: N/A | |
| 6968 | Storage: N /A | |
| 6969 | ||
| 6970 | Note: Alwa ys 1 - Per son | |
| 6971 | 837I: Adde d loop. | |
| 6972 | 837P: Loop has chang ed to 2330 D. | |
| 6973 | 5 | |
| 6974 | Other Paye r Renderin g Sec ID Q ualifier ( 1) | |
| 6975 | 2 A/N | |
| 6976 | 837: | |
| 6977 | (I) 2330G REF01 | |
| 6978 | (P) 2330D REF01 | |
| 6979 | Print: N/A | |
| 6980 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 6981 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 6982 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 6983 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 6984 | Storage: | |
| 6985 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 6986 | Or by Care Unit | |
| 6987 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 6988 | Field: PRO VIDER ID T YPE (#.06) | |
| 6989 | Only 0B, 1 G, G2, LU allowed. | |
| 6990 | 837I: Adde d loop. | |
| 6991 | 837P: Loop has chang ed to 2330 D. | |
| 6992 | 6 | |
| 6993 | Other Paye r Renderin g Sec ID ( 1) | |
| 6994 | 30 A/N | |
| 6995 | 837: | |
| 6996 | (I) 2330G REF02 | |
| 6997 | (P) 2330D REF02 | |
| 6998 | Print: N/A | |
| 6999 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7000 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7001 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7002 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7003 | Storage: | |
| 7004 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7005 | Or by Care Unit | |
| 7006 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7007 | Field: PRO VIDER ID ( #.07) | |
| 7008 | 837I: Adde d loop. | |
| 7009 | 837P: Loop has chang ed to 2330 D. | |
| 7010 | 7 | |
| 7011 | Other Paye r Renderin g Sec ID Q ualifier ( 2) | |
| 7012 | 2 A/N | |
| 7013 | 837: | |
| 7014 | (I) 2330G REF01 | |
| 7015 | (P) 2330D REF01 | |
| 7016 | Print: N/A | |
| 7017 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7018 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7019 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7020 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7021 | Storage: | |
| 7022 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7023 | Or by Care Unit | |
| 7024 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7025 | Field: PRO VIDER ID T YPE (#.06) | |
| 7026 | Only 0B, 1 G, G2, LU allowed. | |
| 7027 | 837I: Adde d loop. | |
| 7028 | 837P: Loop has chang ed to 2330 D. | |
| 7029 | 8 | |
| 7030 | Other Paye r Renderin g Sec ID ( 2) | |
| 7031 | 30 A/N | |
| 7032 | 837: | |
| 7033 | (I) 2330G REF02 | |
| 7034 | (P) 2330D REF02 | |
| 7035 | Print: N/A | |
| 7036 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7037 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7038 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7039 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7040 | Storage: | |
| 7041 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7042 | Or by Care Unit | |
| 7043 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7044 | Field: PRO VIDER ID ( #.07) | |
| 7045 | 837I: Adde d loop. | |
| 7046 | 837P: Loop has chang ed to 2330 D. | |
| 7047 | 9 | |
| 7048 | Other Paye r Renderin g Sec ID Q ualifier ( 3) | |
| 7049 | 2 A/N | |
| 7050 | 837: | |
| 7051 | (I) 2330G REF01 | |
| 7052 | (P) 2330D REF01 | |
| 7053 | Print: N/A | |
| 7054 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7055 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7056 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7057 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7058 | Storage: | |
| 7059 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7060 | Or by Care Unit | |
| 7061 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7062 | Field: PRO VIDER ID T YPE (#.06) | |
| 7063 | Only 0B, 1 G, G2, LU allowed. | |
| 7064 | 837I: Adde d loop. | |
| 7065 | 837P: Loop has chang ed to 2330 D. | |
| 7066 | 10 | |
| 7067 | Other Paye r Renderin g Sec ID ( 3) | |
| 7068 | 30 A/N | |
| 7069 | 837: | |
| 7070 | (I) 2330G REF02 | |
| 7071 | (P) 2330D REF02 | |
| 7072 | Print: N/A | |
| 7073 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7074 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7075 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7076 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7077 | Storage: | |
| 7078 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7079 | Or by Care Unit | |
| 7080 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7081 | Field: PRO VIDER ID ( #.07) | |
| 7082 | 837I: Adde d loop. | |
| 7083 | 837P: Loop has chang ed to 2330 D. | |
| 7084 | ||
| 7085 | OP1A - Loo p 2330C/D (Other Pay er Attendi ng Physici an Data) [SEQ 170.5 ] | |
| 7086 | One record per 2320 record | |
| 7087 | (OPTIONAL – Max leng th 113 byt es) | |
| 7088 | Piece | |
| 7089 | Descriptio n | |
| 7090 | Max Length Data Type | |
| 7091 | 837/Print Location | |
| 7092 | VistA Inpu t/Storage | |
| 7093 | FSC Proces sing Comme nts | |
| 7094 | 1 | |
| 7095 | RECORD ID = ‘OP1A ’ | |
| 7096 | 4 A | |
| 7097 | N/A | |
| 7098 | ||
| 7099 | ||
| 7100 | 2 | |
| 7101 | Payer Resp onsibility Sequence # Code | |
| 7102 | 1 A | |
| 7103 | N/A | |
| 7104 | Biller Inp ut: Screen 3 Section 1 | |
| 7105 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 7106 | Storage: | |
| 7107 | File: BILL /CLAIMS (# 399) | |
| 7108 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 7109 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 7110 | 3 | |
| 7111 | Other Paye r Attendin g Entity I D | |
| 7112 | ||
| 7113 | 2 A/N | |
| 7114 | 837: (I) 2 330C NM101 | |
| 7115 | Print: N/A | |
| 7116 | ||
| 7117 | Biller Inp ut: N/A | |
| 7118 | Storage: N /A | |
| 7119 | Note: Alwa ys 71 | |
| 7120 | 837I: Loop has chang ed to 2330 C. | |
| 7121 | 4 | |
| 7122 | Other Paye r Attendin g Entity T ype Qualif ier | |
| 7123 | ||
| 7124 | 1 N | |
| 7125 | 837: (I) 2 330C NM102 | |
| 7126 | Print: N/A | |
| 7127 | ||
| 7128 | Biller Inp ut: N/A | |
| 7129 | Storage: N /A | |
| 7130 | Note: Alwa ys 1 – Per son | |
| 7131 | 837I: Loop has chang ed to 2330 C; Code 2 deleted on ly 1 allow ed. | |
| 7132 | 5 | |
| 7133 | Other Paye r Attendin g Sec ID Q ualifier ( 1) | |
| 7134 | 2 A/N | |
| 7135 | 837: (I) 2 330C REF01 | |
| 7136 | Print: N/A | |
| 7137 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7138 | When a use r adds a p rovider to a claim, they will be given a n opportun ity to ent er one sec ondary ID. The seco ndary IDs are define d in Provi der ID Mai ntenance. An ID can belong to the provi der or it can be ass igned to t he provide r by the p ayer. | |
| 7139 | VistA will extract u p to the m aximum num ber of pro vider seco ndary IDs into the 8 37. | |
| 7140 | Storage: | |
| 7141 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7142 | Field: PRO VIDER ID T YPE (#.06) | |
| 7143 | Only 0B, 1 G, G2, LU allowed. | |
| 7144 | 837I: Loop has chang ed to 2330 C. | |
| 7145 | 837P: Loop has chang ed to 2330 D. | |
| 7146 | 6 | |
| 7147 | Other Paye r Attendin g Sec ID ( 1) | |
| 7148 | 30 A/N | |
| 7149 | 837: (I) 2 330C REF02 | |
| 7150 | Print: N/A | |
| 7151 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7152 | When a use r adds a p rovider to a claim, they will be given a n opportun ity to ent er one sec ondary ID. The seco ndary IDs are define d in Provi der ID Mai ntenance. An ID can belong to the provi der or it can be ass igned to t he provide r by the p ayer. | |
| 7153 | VistA will extract u p to the m aximum num ber of pro vider seco ndary IDs into the 8 37. | |
| 7154 | Storage: | |
| 7155 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7156 | Field: PRO VIDER ID ( #.07) | |
| 7157 | 837I: Loop has chang ed to 2330 C. | |
| 7158 | 7 | |
| 7159 | Other Paye r Attendin g Sec ID Q ualifier ( 2) | |
| 7160 | 2 A/N | |
| 7161 | 837: (I) 2 330C REF01 | |
| 7162 | Print: N/A | |
| 7163 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7164 | Billers ad d the prov ider to th e claim. | |
| 7165 | Storage: | |
| 7166 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7167 | Field: PRO VIDER ID T YPE (#.06) | |
| 7168 | Only 0B, 1 G, G2, LU allowed. | |
| 7169 | 837I: Loop has chang ed to 2330 C. | |
| 7170 | 8 | |
| 7171 | Other Paye r Attendin g Sec ID ( 2) | |
| 7172 | 30 A/N | |
| 7173 | 837: (I) 2 330C REF02 | |
| 7174 | Print: N/A | |
| 7175 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7176 | Billers ad d the prov ider to th e claim. | |
| 7177 | Storage: | |
| 7178 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7179 | Field: PRO VIDER ID ( #.07) | |
| 7180 | 837I: Loop has chang ed to 2330 C. | |
| 7181 | 9 | |
| 7182 | Other Paye r Attendin g Sec ID Q ualifier ( 3) | |
| 7183 | 2 A/N | |
| 7184 | 837: (I) 2 330C REF01 | |
| 7185 | Print: N/A | |
| 7186 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7187 | Billers ad d the prov ider to th e claim. | |
| 7188 | Storage: | |
| 7189 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7190 | Field: PRO VIDER ID T YPE (#.06) | |
| 7191 | Only 0B, 1 G, G2, LU allowed. | |
| 7192 | 837I: Loop has chang ed to 2330 C. | |
| 7193 | 10 | |
| 7194 | Other Paye r Attendin g Sec ID ( 3) | |
| 7195 | 30 A/N | |
| 7196 | 837: (I) 2 330C REF02 | |
| 7197 | Print: N/ A | |
| 7198 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7199 | Billers ad d the prov ider to th e claim. | |
| 7200 | Storage: | |
| 7201 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7202 | Field: PRO VIDER ID ( #.07) | |
| 7203 | 837I: Loop has chang ed to 2330 C. | |
| 7204 | ||
| 7205 | OP2 - Loop 2330D (Ot her Payer Operating Physician Data) [SEQ 171] | |
| 7206 | One record per 2320 record | |
| 7207 | (OPTIONAL – Max leng th 113 byt es) | |
| 7208 | Piece | |
| 7209 | Descriptio n | |
| 7210 | Max Length Data Type | |
| 7211 | 837/Print Location | |
| 7212 | VistA Inpu t/Storage | |
| 7213 | FSC Proces sing Comme nts | |
| 7214 | 1 | |
| 7215 | RECORD ID = ‘OP2 ’ | |
| 7216 | 4 A | |
| 7217 | N/A | |
| 7218 | ||
| 7219 | ||
| 7220 | 2 | |
| 7221 | Payer Resp onsibility Sequence # Code | |
| 7222 | 1 A | |
| 7223 | N/A | |
| 7224 | Biller Inp ut: Screen 3 Section 1 | |
| 7225 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 7226 | Storage: | |
| 7227 | File: BILL /CLAIMS (# 399) | |
| 7228 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 7229 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 7230 | 3 | |
| 7231 | Other Paye r Operatin g Phy Enti ty ID | |
| 7232 | 2 A/N | |
| 7233 | 837: (I) 2 330D NM101 | |
| 7234 | Print: N/A | |
| 7235 | ||
| 7236 | Biller Inp ut: N/A | |
| 7237 | Storage: N /A | |
| 7238 | Note: Alwa ys 72 | |
| 7239 | 837I: Loop has chang ed to 2330 D. | |
| 7240 | ||
| 7241 | 4 | |
| 7242 | Other Paye r Operatin g Phy Enti ty Qualifi er | |
| 7243 | 1 N | |
| 7244 | 837: (I) 2 330D NM102 | |
| 7245 | Print: N/A | |
| 7246 | Biller Inp ut: N/A | |
| 7247 | Storage: N /A | |
| 7248 | Note: Alwa ys 1 - Per son | |
| 7249 | 837I: Loop has chang ed to 2330 D. | |
| 7250 | Code set c hange: | |
| 7251 | ID qualifi ers allowe d are 0B, 1G, G2 and LU. | |
| 7252 | 5 | |
| 7253 | Other Paye r Oper Phy Sec ID Qu alifier (1 ) | |
| 7254 | 2 A/N | |
| 7255 | 837: (I) 2 330D REF01 | |
| 7256 | Print: N/A | |
| 7257 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7258 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7259 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7260 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7261 | Storage: | |
| 7262 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7263 | Or by Care Unit | |
| 7264 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7265 | Field: PRO VIDER ID T YPE (#.06) | |
| 7266 | 837I: Loop has chang ed to 2330 D. | |
| 7267 | ||
| 7268 | Code set c hange: | |
| 7269 | ID qualifi ers allowe d are 0B, 1G, G2 and LU. | |
| 7270 | 6 | |
| 7271 | Other Paye r Operatin g Phy Sec ID (1) | |
| 7272 | 30 A/N | |
| 7273 | 837: (I) 2 330D REF02 | |
| 7274 | Print: N/A | |
| 7275 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7276 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7277 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7278 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7279 | Storage: | |
| 7280 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7281 | Or by Care Unit | |
| 7282 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7283 | Field: PRO VIDER ID ( #.07) | |
| 7284 | 837I: Loop has chang ed to 2330 D. | |
| 7285 | ||
| 7286 | 7 | |
| 7287 | Other Paye r Oper Phy Sec ID Qu alifier (2 ) | |
| 7288 | 2 A/N | |
| 7289 | 837: (I) 2 330D REF01 | |
| 7290 | Print: N/A | |
| 7291 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7292 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7293 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7294 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7295 | Storage: | |
| 7296 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7297 | Or by Care Unit | |
| 7298 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7299 | Field: PRO VIDER ID T YPE (#.06) | |
| 7300 | 837I: Loop has chang ed to 2330 D. | |
| 7301 | ||
| 7302 | Code set c hange: | |
| 7303 | ID qualifi ers allowe d are 0B, 1G, G2 and LU. | |
| 7304 | 8 | |
| 7305 | Other Paye r Operatin g Phy Sec ID (2) | |
| 7306 | 30 A/N | |
| 7307 | 837: (I) 2 330D REF02 | |
| 7308 | Print: N/A | |
| 7309 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7310 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7311 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7312 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7313 | Storage: | |
| 7314 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7315 | Or by Care Unit | |
| 7316 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7317 | Field: PRO VIDER ID ( #.07) | |
| 7318 | 837I: Loop has chang ed to 2330 D. | |
| 7319 | ||
| 7320 | 9 | |
| 7321 | Other Paye r Oper Phy Sec ID Qu alifier (3 ) | |
| 7322 | 2 A/N | |
| 7323 | 837: (I) 2 330D REF01 | |
| 7324 | Print: N/A | |
| 7325 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7326 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7327 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7328 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7329 | Storage: | |
| 7330 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7331 | Or by Care Unit | |
| 7332 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7333 | Field: PRO VIDER ID T YPE (#.06) | |
| 7334 | 837I: Loop has chang ed to 2330 D. | |
| 7335 | ||
| 7336 | Code set c hange: | |
| 7337 | ID qualifi ers allowe d are 0B, 1G, G2 and LU. | |
| 7338 | 10 | |
| 7339 | Other Paye r Operatin g Phy Sec ID (3) | |
| 7340 | 30 A/N | |
| 7341 | 837: (I) 2 330D REF02 | |
| 7342 | Print: N/A | |
| 7343 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7344 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7345 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7346 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7347 | Storage: | |
| 7348 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7349 | Or by Care Unit | |
| 7350 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7351 | Field: PRO VIDER ID ( #.07) | |
| 7352 | 837I: Loop has chang ed to 2330 D. | |
| 7353 | ||
| 7354 | ||
| 7355 | OP3 - Loop 2330F (Ot her Payer Service Fa cility Dat a) [SEQ 17 2] | |
| 7356 | One record per 2320 record | |
| 7357 | (OPTIONAL – Max leng th 113 byt es) | |
| 7358 | Piece | |
| 7359 | Descriptio n | |
| 7360 | Max Length Data Type | |
| 7361 | 837/Print Location | |
| 7362 | VistA Inpu t/Storage | |
| 7363 | FSC Proces sing Comme nts | |
| 7364 | 1 | |
| 7365 | RECORD ID = ‘OP3 ’ | |
| 7366 | 4 A | |
| 7367 | N/A | |
| 7368 | ||
| 7369 | ||
| 7370 | 2 | |
| 7371 | Payer Resp onsibility Sequence # Code | |
| 7372 | 1 A | |
| 7373 | N/A | |
| 7374 | Biller Inp ut: Screen 3 Section 1 | |
| 7375 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 7376 | Storage: | |
| 7377 | File: BILL /CLAIMS (# 399) | |
| 7378 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 7379 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 7380 | 3 | |
| 7381 | Other Paye r Lab/Faci lity Entit y ID | |
| 7382 | 2 A/N | |
| 7383 | 837: (I) 2 330F NM101 | |
| 7384 | Print: N/A | |
| 7385 | Biller Inp ut: N/A | |
| 7386 | Storage: N /A | |
| 7387 | Note: Alwa ys 77 | |
| 7388 | 837I: Loop has chang ed to 2330 F. | |
| 7389 | Code set c hange: | |
| 7390 | 77 is not the only a llowed cod e. | |
| 7391 | 4 | |
| 7392 | Other Paye r Lab / Fa c Entity Q ualifier | |
| 7393 | 1 N | |
| 7394 | 837: (I) 2 330F NM102 | |
| 7395 | Print: N/A | |
| 7396 | ||
| 7397 | Biller Inp ut: N/A | |
| 7398 | Storage: N /A | |
| 7399 | Note: Alwa ys 2- Non- Person | |
| 7400 | 837I: Loop has chang ed to 2330 F. | |
| 7401 | 5 | |
| 7402 | Other Paye r Lab/Fac Sec ID Qua lifier (1) | |
| 7403 | 2 A/N | |
| 7404 | 837: (I) 2 330F REF01 | |
| 7405 | Print: N/A | |
| 7406 | Biller Inp ut: | |
| 7407 | Fee: Scree n 10 Secti on 4 | |
| 7408 | Users may add an Out side Facil ity to a claim but the facili ty is defi ned in SYS TPROVNF of Provider ID Mainten ance. Sec ondary IDs can be th e provider ’s own ID or an ID a ssigned by a payer. | |
| 7409 | Storage: | |
| 7410 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7411 | Field: PRO VIDER ID T YPE (#.06) | |
| 7412 | 837I: Loop has chang ed to 2330 F. | |
| 7413 | ||
| 7414 | Code set c hange: | |
| 7415 | ID qualifi ers allowe d are 0B, G2 and LU. | |
| 7416 | 6 | |
| 7417 | Other Paye r Lab/Faci lity Sec I D (1) | |
| 7418 | 30 A/N | |
| 7419 | 837: (I) 2 330F REF02 | |
| 7420 | Print: N/A | |
| 7421 | Biller Inp ut: | |
| 7422 | Fee: Scree n 10 Secti on 4 | |
| 7423 | Storage: | |
| 7424 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7425 | Field: PRO VIDER ID ( #.07) | |
| 7426 | 837I: Loop has chang ed to 2330 F. | |
| 7427 | 7 | |
| 7428 | Other Paye r Lab/Fac Sec ID Qua lifier (2) | |
| 7429 | 2 A/N | |
| 7430 | 837: (I) 2 330F REF01 | |
| 7431 | Print: N/A | |
| 7432 | Biller Inp ut: | |
| 7433 | Fee: Scree n 10 Secti on 4 | |
| 7434 | Users may add an Out side Facil ity to a claim but the facili ty is defi ned in SYS TPROVNF of Provider ID Mainten ance. Sec ondary IDs can be th e provider ’s own ID or an ID a ssigned by a payer. | |
| 7435 | Storage: | |
| 7436 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7437 | Field: PRO VIDER ID T YPE (#.06) | |
| 7438 | 837I: Loop has chang ed to 2330 F. | |
| 7439 | ||
| 7440 | Code set c hange: | |
| 7441 | ID qualifi ers allowe d are 0B, G2 and LU. | |
| 7442 | 8 | |
| 7443 | Other Paye r Lab/Faci lity Sec I D (2) | |
| 7444 | 30 A/N | |
| 7445 | 837: (I) 2 330F REF02 | |
| 7446 | Print: N/A | |
| 7447 | Biller Inp ut: | |
| 7448 | Fee: Scree n 10 Secti on 4 | |
| 7449 | Storage: | |
| 7450 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7451 | Field: PRO VIDER ID ( #.07) | |
| 7452 | 837I: Loop has chang ed to 2330 F. | |
| 7453 | 9 | |
| 7454 | Other Paye r Lab/Fac Sec ID Qua lifier (3) | |
| 7455 | 2 A/N | |
| 7456 | 837: (I) 2 330F REF01 | |
| 7457 | Print: N/A | |
| 7458 | Biller Inp ut: | |
| 7459 | Fee: Scree n 10 Secti on 4 | |
| 7460 | Users may add an Out side Facil ity to a claim but the facili ty is defi ned in SYS TPROVNF of Provider ID Mainten ance. Sec ondary IDs can be th e provider ’s own ID or an ID a ssigned by a payer. | |
| 7461 | Storage: | |
| 7462 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7463 | Field: PRO VIDER ID T YPE (#.06) | |
| 7464 | 837I: Loop has chang ed to 2330 F. | |
| 7465 | ||
| 7466 | Code set c hange: | |
| 7467 | ID qualifi ers allowe d are 0B, G2 and LU. | |
| 7468 | 10 | |
| 7469 | Other Paye r Lab/Faci lity Sec I D (3) | |
| 7470 | 30 A/N | |
| 7471 | 837(I) 233 0F REF02 | |
| 7472 | Print: N/A | |
| 7473 | Biller Inp ut: | |
| 7474 | Fee: Scree n 10 Secti on 4 | |
| 7475 | Storage: | |
| 7476 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7477 | Field: PRO VIDER ID ( #.07) | |
| 7478 | 837I: Loop has chang ed to 2330 F. | |
| 7479 | ||
| 7480 | OP4 - Loop 2330C (Ot her Payer Referring Provider D ata) [SEQ 173] | |
| 7481 | One record per 2320 record | |
| 7482 | (OPTIONAL – Max leng th 113 byt es) | |
| 7483 | Piece | |
| 7484 | Descriptio n | |
| 7485 | Max Length Data Type | |
| 7486 | 837/Print Location | |
| 7487 | VistA Inpu t/Storage | |
| 7488 | FSC Proces sing Comme nts | |
| 7489 | 1 | |
| 7490 | RECORD ID = ‘OP4 ’ | |
| 7491 | 4 A | |
| 7492 | ||
| 7493 | ||
| 7494 | ||
| 7495 | 2 | |
| 7496 | Payer Resp onsibility Sequence # Code | |
| 7497 | 1 A | |
| 7498 | ||
| 7499 | Biller Inp ut: Screen 3 Section 1 | |
| 7500 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 7501 | Storage: | |
| 7502 | File: BILL /CLAIMS (# 399) | |
| 7503 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 7504 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 7505 | 3 | |
| 7506 | Other Paye r Referrin g Prov Ent ity ID | |
| 7507 | 2 A/N | |
| 7508 | 837: | |
| 7509 | (P) 2330C NM101 | |
| 7510 | (I) 2330H NM101 | |
| 7511 | Print: N/A | |
| 7512 | ||
| 7513 | Biller Inp ut: N/A | |
| 7514 | Storage: N /A | |
| 7515 | Note: Alwa ys DN | |
| 7516 | 837P: Loop Change to 2330C. | |
| 7517 | ||
| 7518 | 4 | |
| 7519 | Other Paye r Referrin g Prov Ent ity Qualif ier | |
| 7520 | 1 N | |
| 7521 | 837: | |
| 7522 | (P) 2330C NM102 | |
| 7523 | (I) 2330H NM102 | |
| 7524 | Print: N/A | |
| 7525 | ||
| 7526 | Biller Inp ut: N/A | |
| 7527 | Storage: N /A | |
| 7528 | Note: Alwa ys 1 - Per son | |
| 7529 | 837P: Loop Change to 2330C. | |
| 7530 | ||
| 7531 | 5 | |
| 7532 | Other Paye r Refer Pr ov Sec ID Qualifier (1) | |
| 7533 | 2 A/N | |
| 7534 | 837: | |
| 7535 | (P) 2330C REF01 | |
| 7536 | (I) 2330H REF01 | |
| 7537 | Print: N/A | |
| 7538 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7539 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7540 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7541 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7542 | Storage: | |
| 7543 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7544 | Or by Care Unit | |
| 7545 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7546 | Field: PRO VIDER ID T YPE (#.06) | |
| 7547 | 837P: Loop Change to 2330C. | |
| 7548 | ||
| 7549 | Code set c hange: | |
| 7550 | ID qualifi ers allowe d are 0B, 1G and G2. | |
| 7551 | 6 | |
| 7552 | Other Paye r Referrin g Prov Sec ID (1) | |
| 7553 | 30 A/N | |
| 7554 | 837: | |
| 7555 | (P) 2330C REF02 | |
| 7556 | (I) 2330H REF02 | |
| 7557 | Print: N/A | |
| 7558 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7559 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7560 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7561 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7562 | Storage: | |
| 7563 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7564 | Or by Care Unit | |
| 7565 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7566 | Field: PRO VIDER ID ( #.07) | |
| 7567 | 837P: Loop Change to 2330C. | |
| 7568 | ||
| 7569 | 7 | |
| 7570 | Other Paye r Refer Pr ov Sec ID Qualifier (2) | |
| 7571 | 2 A/N | |
| 7572 | 837: | |
| 7573 | (P) 2330C REF01 | |
| 7574 | (I) 2330H REF01 | |
| 7575 | Print: N/A | |
| 7576 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7577 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7578 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7579 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7580 | Storage: | |
| 7581 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7582 | Or by Care Unit | |
| 7583 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7584 | Field: PRO VIDER ID T YPE (#.06) | |
| 7585 | 837P: Loop Change to 2330C. | |
| 7586 | ||
| 7587 | Code set c hange: | |
| 7588 | ID qualifi ers allowe d are 0B, 1G and G2. | |
| 7589 | 8 | |
| 7590 | Other Paye r Referrin g Prov Sec ID (2) | |
| 7591 | 30 A/N | |
| 7592 | 837: | |
| 7593 | (P) 2330C REF02 | |
| 7594 | (I) 2330H REF02 | |
| 7595 | Print: N/A | |
| 7596 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7597 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7598 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7599 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7600 | Storage: | |
| 7601 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7602 | Or by Care Unit | |
| 7603 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7604 | Field: PRO VIDER ID ( #.07) | |
| 7605 | 837P: Loop Change to 2330C. | |
| 7606 | 9 | |
| 7607 | Other Paye r Refer Pr ov Sec ID Qualifier (3) | |
| 7608 | 2 A/N | |
| 7609 | 837: | |
| 7610 | (P) 2330C REF01 | |
| 7611 | (I) 2330H REF01 | |
| 7612 | Print: N/A | |
| 7613 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7614 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7615 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7616 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7617 | Storage: | |
| 7618 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7619 | Or by Care Unit | |
| 7620 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7621 | Field: PRO VIDER ID T YPE (#.06) | |
| 7622 | ID qualifi ers allowe d are 0B, 1G and G2. | |
| 7623 | 10 | |
| 7624 | Other Paye r Referrin g Prov Sec ID (3) | |
| 7625 | 30 A/N | |
| 7626 | 837: | |
| 7627 | (P) 2330C REF02 | |
| 7628 | (I) 2330H REF02 | |
| 7629 | Print: N/A | |
| 7630 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7631 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7632 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7633 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7634 | Storage: | |
| 7635 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7636 | Or by Care Unit | |
| 7637 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7638 | Field: PRO VIDER ID ( #.07) | |
| 7639 | 837P: Loop Change to 2330C. | |
| 7640 | 837I: Loop 2330F has been adde d for a Re ferring Pr ovider. | |
| 7641 | ||
| 7642 | OP7 - Loop 2330E (Ot her Payer Service Fa cility Dat a) [SEQ 17 6] | |
| 7643 | (OPTIONAL – Max leng th 113 byt es) | |
| 7644 | Piece | |
| 7645 | Descriptio n | |
| 7646 | Max Length Data Type | |
| 7647 | 837/Print Location | |
| 7648 | VistA Inpu t/Storage | |
| 7649 | FSC Proces sing Comme nts | |
| 7650 | 1 | |
| 7651 | RECORD ID = ‘OP7 ’ | |
| 7652 | 4 A | |
| 7653 | N/A | |
| 7654 | ||
| 7655 | ||
| 7656 | 2 | |
| 7657 | Payer Resp onsibility Sequence # Code | |
| 7658 | 1 A | |
| 7659 | N/A | |
| 7660 | Biller Inp ut: Screen 3 Section 1 | |
| 7661 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 7662 | Storage: | |
| 7663 | File: BILL /CLAIMS (# 399) | |
| 7664 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 7665 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 7666 | 3 | |
| 7667 | Other Paye r Service Facility E ntity ID | |
| 7668 | ||
| 7669 | 2 A/N | |
| 7670 | 837: (P) 2 330E NM101 | |
| 7671 | Print: N/A | |
| 7672 | Biller Inp ut: N/A | |
| 7673 | Storage: N /A | |
| 7674 | Note: Alwa ys 77 | |
| 7675 | Loop has c hanged to 2330E. | |
| 7676 | ||
| 7677 | Code set c hange: | |
| 7678 | 77 is now the only a llowed cod e. | |
| 7679 | 4 | |
| 7680 | Other Paye r Service Fac Entity Qualifier | |
| 7681 | 1 N | |
| 7682 | 837: (P) 2 330E NM102 | |
| 7683 | Print: N/A | |
| 7684 | Biller Inp ut: N/A | |
| 7685 | Storage: N /A | |
| 7686 | Note: Alwa ys 2 – Non -Person | |
| 7687 | Loop has c hanged to 2330E. | |
| 7688 | 5 | |
| 7689 | Other Paye r Service Fac Sec ID Qualifier (1) | |
| 7690 | 2 A/N | |
| 7691 | 837: (P) 2 330E REF01 | |
| 7692 | Print: N/A | |
| 7693 | ||
| 7694 | Biller Inp ut: | |
| 7695 | Fee: Scree n 10 Secti on 4 | |
| 7696 | Users may add an Out side Facil ity to a claim but the facili ty is defi ned in SYS TPROVNF of Provider ID Mainten ance. Sec ondary IDs can be th e provider ’s own ID or an ID a ssigned by a payer. | |
| 7697 | Storage: | |
| 7698 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7699 | Field: PRO VIDER ID T YPE (#.06) | |
| 7700 | Loop has c hanged to 2330E. | |
| 7701 | ||
| 7702 | Code set c hange: | |
| 7703 | ID qualifi ers allowe d are 0B, G2 and LU. | |
| 7704 | 6 | |
| 7705 | Other Paye r Service Facility S ec ID (1) | |
| 7706 | 30 A/N | |
| 7707 | 837: (P) 2 330E REF02 | |
| 7708 | Print: N/A | |
| 7709 | Biller Inp ut: | |
| 7710 | Fee: Scree n 10 Secti on 4 | |
| 7711 | Storage: | |
| 7712 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7713 | Field: PRO VIDER ID ( #.07) | |
| 7714 | Loop has changed to 2330E. | |
| 7715 | 7 | |
| 7716 | Other Paye r Service Fac Sec ID Qualifier (2) | |
| 7717 | 2 A/N | |
| 7718 | 837: (P) 2 330E REF01 | |
| 7719 | Print: N/A | |
| 7720 | Biller Inp ut: | |
| 7721 | Fee: Scree n 10 Secti on 4 | |
| 7722 | Users may add an Out side Facil ity to a claim but the facili ty is defi ned in SYS TPROVNF of Provider ID Mainten ance. Sec ondary IDs can be th e provider ’s own ID or an ID a ssigned by a payer. | |
| 7723 | Storage: | |
| 7724 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7725 | Field: PRO VIDER ID T YPE (#.06) | |
| 7726 | Loop has c hanged to 2330E. | |
| 7727 | ||
| 7728 | Code set c hange: | |
| 7729 | ID qualifi ers allowe d are 0B, G2 and LU. | |
| 7730 | 8 | |
| 7731 | Other Paye r Service Facility S ec ID (2) | |
| 7732 | 30 A/N | |
| 7733 | 837: (P) 2 330E REF02 | |
| 7734 | Print: N/A | |
| 7735 | Biller Inp ut: | |
| 7736 | Fee: Scree n 10 Secti on 4 | |
| 7737 | Storage: | |
| 7738 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7739 | Field: PRO VIDER ID ( #.07) | |
| 7740 | Loop has c hanged to 2330E. | |
| 7741 | 9 | |
| 7742 | Other Paye r Service Fac Sec ID Qualifier (2) | |
| 7743 | 2 A/N | |
| 7744 | 837: (P) 2 330E REF01 | |
| 7745 | Print: N/A | |
| 7746 | Biller Inp ut: | |
| 7747 | Fee: Scree n 10 Secti on 4 | |
| 7748 | Users may add an Out side Facil ity to a claim but the facili ty is defi ned in SYS TPROVNF of Provider ID Mainten ance. Sec ondary IDs can be th e provider ’s own ID or an ID a ssigned by a payer. | |
| 7749 | Storage: | |
| 7750 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7751 | Field: PRO VIDER ID T YPE (#.06) | |
| 7752 | Loop has c hanged to 2330E. | |
| 7753 | ||
| 7754 | Code set c hange: | |
| 7755 | ID qualifi ers allowe d are 0B, G2 and LU. | |
| 7756 | 10 | |
| 7757 | Other Paye r Service Facility S ec ID (3) | |
| 7758 | 30 A/N | |
| 7759 | 837: (P) 2 330E REF02 | |
| 7760 | Print: N/A | |
| 7761 | Biller Inp ut: | |
| 7762 | Fee: Scree n 10 Secti on 4 | |
| 7763 | Storage: | |
| 7764 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7765 | Field: PRO VIDER ID ( #.07) | |
| 7766 | Loop has c hanged to 2330E. | |
| 7767 | ||
| 7768 | ||
| 7769 | OP8 - Loop 2330F (Ot her Payer Supervisin g Provider Data) [SE Q 177] | |
| 7770 | One record per 2320 record | |
| 7771 | (OPTIONAL – Max leng th 113 byt es) | |
| 7772 | Piece | |
| 7773 | Descriptio n | |
| 7774 | Max Length Data Type | |
| 7775 | 837/Print Location | |
| 7776 | VistA Inpu t/Storage | |
| 7777 | FSC Proces sing Comme nts | |
| 7778 | 1 | |
| 7779 | RECORD ID = ‘OP8 ’ | |
| 7780 | 4 A | |
| 7781 | N/A | |
| 7782 | ||
| 7783 | ||
| 7784 | 2 | |
| 7785 | Payer Resp onsibility Sequence # Code | |
| 7786 | 1 A | |
| 7787 | N/A | |
| 7788 | Biller Inp ut: Screen 3 Section 1 | |
| 7789 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 7790 | Storage: | |
| 7791 | File: BILL /CLAIMS (# 399) | |
| 7792 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 7793 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 7794 | 3 | |
| 7795 | Other Paye r Supervis ing Prov E ntity ID | |
| 7796 | 2 A/N | |
| 7797 | 837: (P) 2 330F NM101 | |
| 7798 | Print: N/A | |
| 7799 | Biller Inp ut: N/A | |
| 7800 | Storage: N /A | |
| 7801 | Note: Alwa ys DQ | |
| 7802 | Loop chan ged to 233 0F. | |
| 7803 | 4 | |
| 7804 | Other Paye r Super Pr ov Entity Qualifier | |
| 7805 | 1 N | |
| 7806 | 837: (P) 2 330F NM102 | |
| 7807 | Print: N/A | |
| 7808 | Biller Inp ut: N/A | |
| 7809 | Storage: N /A | |
| 7810 | Note: Alwa ys 1 - Per son | |
| 7811 | Loop chang ed to 2330 F. | |
| 7812 | 5 | |
| 7813 | Other Paye r Supervis ing Prov S ec ID Qual ifier (1) | |
| 7814 | 2 A/N | |
| 7815 | 837: (P) 2 330F REF01 | |
| 7816 | Print: N/A | |
| 7817 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7818 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7819 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7820 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7821 | Storage: | |
| 7822 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7823 | Or by Care Unit | |
| 7824 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7825 | Field: PRO VIDER ID T YPE (#.06) | |
| 7826 | Loop chang e to 2330F . | |
| 7827 | ||
| 7828 | Code Set C hange: | |
| 7829 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 7830 | 6 | |
| 7831 | Other Paye r Supervis ing Prov S ec ID (1) | |
| 7832 | 30 A/N | |
| 7833 | 837: (P) 2 330F REF02 | |
| 7834 | Print: N/A | |
| 7835 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7836 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7837 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7838 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7839 | Storage: | |
| 7840 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7841 | Or by Care Unit | |
| 7842 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7843 | Field: PRO VIDER ID ( #.07) | |
| 7844 | Loop chang e to 2330F . | |
| 7845 | 7 | |
| 7846 | Other Paye r Supervis ing Prov S ec ID Qual ifier (2) | |
| 7847 | 2 A/N | |
| 7848 | 837: (P) 2 330F REF01 | |
| 7849 | Print: N/A | |
| 7850 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7851 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7852 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7853 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7854 | Storage: | |
| 7855 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7856 | Or by Care Unit | |
| 7857 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7858 | Field: PRO VIDER ID T YPE (#.06) | |
| 7859 | Loop chang e to 2330F . | |
| 7860 | ||
| 7861 | Code Set C hange: | |
| 7862 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 7863 | 8 | |
| 7864 | Other Paye r Supervis ing Prov S ec ID (2) | |
| 7865 | 30 A/N | |
| 7866 | 837: (P) 2 330F REF02 | |
| 7867 | Print: N/A | |
| 7868 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7869 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7870 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7871 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7872 | Storage: | |
| 7873 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7874 | Or by Care Unit | |
| 7875 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7876 | Field: PRO VIDER ID ( #.07) | |
| 7877 | Loop chang e to 2330F . | |
| 7878 | 9 | |
| 7879 | Other Paye r Supervis ing Prov S ec ID Qual ifier (3) | |
| 7880 | 2 A/N | |
| 7881 | 837: (P) 2 330F REF01 | |
| 7882 | Print: N/A | |
| 7883 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7884 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7885 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7886 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7887 | Storage: | |
| 7888 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7889 | Or by Care Unit | |
| 7890 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7891 | Field: PRO VIDER ID T YPE (#.06) | |
| 7892 | Loop chan ge to 2330 F. | |
| 7893 | ||
| 7894 | Code Set C hange: | |
| 7895 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 7896 | 10 | |
| 7897 | Other Paye r Supervis ing Prov S ec ID (3) | |
| 7898 | 30 A/N | |
| 7899 | 837: (P) 2 330F REF02 | |
| 7900 | Print: N/A | |
| 7901 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7902 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7903 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7904 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7905 | Storage: | |
| 7906 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7907 | Or by Care Unit | |
| 7908 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7909 | Field: PRO VIDER ID ( #.07) | |
| 7910 | Loop chang e to 2330F . | |
| 7911 | ||
| 7912 | OP9 - Loop 2330E (Ot her Payer Other Oper ating Prov ider Data) [SEQ 178] | |
| 7913 | One record per 2320 record | |
| 7914 | (OPTIONAL – Max leng th 113 byt es) | |
| 7915 | Piece | |
| 7916 | Descriptio n | |
| 7917 | Max Length Data Type | |
| 7918 | 837/Print Location | |
| 7919 | VistA Inpu t/Storage | |
| 7920 | FSC Proces sing Comme nts | |
| 7921 | 1 | |
| 7922 | RECORD ID = ‘OP9 ’ | |
| 7923 | 4 A | |
| 7924 | N/A | |
| 7925 | ||
| 7926 | ||
| 7927 | 2 | |
| 7928 | Payer Resp onsibility Sequence # Code | |
| 7929 | 1 A | |
| 7930 | 837: N/A | |
| 7931 | Print: N/A | |
| 7932 | Biller Inp ut: Screen 3 Section 1 | |
| 7933 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 7934 | Storage: | |
| 7935 | File: BILL /CLAIMS (# 399) | |
| 7936 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 7937 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 7938 | 3 | |
| 7939 | Other Paye r Other Op erating Pr ov Entity ID Code | |
| 7940 | 2 A/N | |
| 7941 | 837: (I) 2 330E NM101 | |
| 7942 | Print: N/A | |
| 7943 | Biller Inp ut: N/A | |
| 7944 | Storage: N /A | |
| 7945 | Note: Alwa ys ZZ | |
| 7946 | 837I: Loop changed t o 2330E. | |
| 7947 | 4 | |
| 7948 | Other Paye r Other Op erating Pr ov Entity Qualifier | |
| 7949 | 1 N | |
| 7950 | 837: (I) 2 330E NM102 | |
| 7951 | Print: N/A | |
| 7952 | Biller Inp ut: N/A | |
| 7953 | Storage: N /A | |
| 7954 | Note: Alwa ys 1 - Per son | |
| 7955 | 837I: Loop changed t o 2330E. | |
| 7956 | 5 | |
| 7957 | Other Paye r Other Op erating Pr ov Sec ID Qualifier (1) | |
| 7958 | 2 A/N | |
| 7959 | 837: N/A | |
| 7960 | Print: N/A | |
| 7961 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7962 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7963 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7964 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7965 | Storage: | |
| 7966 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7967 | Or by Care Unit | |
| 7968 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7969 | Field: PRO VIDER ID T YPE (#.06) | |
| 7970 | 837I: Loop changed t o 2330E. | |
| 7971 | ||
| 7972 | Code Set C hange: | |
| 7973 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 7974 | 6 | |
| 7975 | Other Paye r Other Op erating Pr ov Sec ID (1) | |
| 7976 | 30 A/N | |
| 7977 | 837: (I) 2 330E RE02 | |
| 7978 | Print: N/A | |
| 7979 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7980 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7981 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7982 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7983 | Storage: | |
| 7984 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 7985 | Or by Care Unit | |
| 7986 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 7987 | Field: PRO VIDER ID ( #.07) | |
| 7988 | 837I: Loop changed t o 2330E. | |
| 7989 | 7 | |
| 7990 | Other Paye r Other Pr ov Sec ID Qualifier (2) | |
| 7991 | 2 A/N | |
| 7992 | 837: (I) 2 330E REF01 | |
| 7993 | Print: N/A | |
| 7994 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 7995 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 7996 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 7997 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 7998 | Storage: | |
| 7999 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 8000 | Or by Care Unit | |
| 8001 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 8002 | Field: PRO VIDER ID T YPE (#.06) | |
| 8003 | 837I: Loop changed t o 2330E. | |
| 8004 | ||
| 8005 | Name chang ed from Ot her Provid er to Othe r Operatin g Provider . Usage o nly allowe d when an Operating Provider i s specifie d in 2310B . | |
| 8006 | ||
| 8007 | Code Set C hange: | |
| 8008 | Only codes now allow ed are 0B, 1G, G2 an d LU. | |
| 8009 | 8 | |
| 8010 | Other Paye r Other Op erating Pr ov Sec ID (2) | |
| 8011 | 30 A/N | |
| 8012 | 837: (I) 2 330E REF02 | |
| 8013 | Print: N/A | |
| 8014 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 8015 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 8016 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 8017 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 8018 | Storage: | |
| 8019 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 8020 | Or by Care Unit | |
| 8021 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 8022 | Field: PRO VIDER ID ( #.07) | |
| 8023 | 837I: Loop changed t o 2330E. | |
| 8024 | 9 | |
| 8025 | Other Paye r Other Op erating Pr ov Sec ID Qualifier (3) | |
| 8026 | 2 A/N | |
| 8027 | 837: (I) 2 330E REF01 | |
| 8028 | Print: N/A | |
| 8029 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 8030 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 8031 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 8032 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 8033 | Storage: | |
| 8034 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 8035 | Or by Care Unit | |
| 8036 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 8037 | Field: PRO VIDER ID T YPE (#.06) | |
| 8038 | 837I: Loop changed t o 2330E. | |
| 8039 | ||
| 8040 | Name chang ed from Ot her Provid er to Othe r Operatin g Provider . Usage o nly allowe d when an Operating Provider i s specifie d in 2310B . | |
| 8041 | ||
| 8042 | Code Set C hange: | |
| 8043 | Only codes now allow ed are 0B, 1G, G2, L U. | |
| 8044 | 10 | |
| 8045 | Other Paye r Other Pr ov Sec ID (3) | |
| 8046 | 30 A/N | |
| 8047 | 837: (I) 2 330E REF02 | |
| 8048 | Print: N/A | |
| 8049 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 8050 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 8051 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 8052 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 8053 | Storage: | |
| 8054 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 8055 | Or by Care Unit | |
| 8056 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 8057 | Field: PRO VIDER ID ( #.07) | |
| 8058 | 837I: Loop changed t o 2330E. | |
| 8059 | ||
| 8060 | Section 5 – Line Lev el Data | |
| 8061 | PRF - Loop 2400 (Pro fessional Service Li ne Data) [ SEQ 180] | |
| 8062 | One or mor e records per Claim Data recor d | |
| 8063 | (OPTIONAL – Max leng th 212 by tes) | |
| 8064 | Piece | |
| 8065 | Descriptio n | |
| 8066 | Max Length Data Type | |
| 8067 | 837/Print Location | |
| 8068 | VistA Inpu t/Storage | |
| 8069 | FSC Proces sing Comme nts | |
| 8070 | 1 | |
| 8071 | RECORD ID = ‘PRF ’ | |
| 8072 | 4 A | |
| 8073 | ||
| 8074 | ||
| 8075 | ||
| 8076 | 2 | |
| 8077 | Service Li ne # | |
| 8078 | 6 N | |
| 8079 | 837: (P) 2 400 LX01 | |
| 8080 | Print: N/A | |
| 8081 | Biller Inp ut: Screen 5 Section 4 | |
| 8082 | For each p rocedure o n a claim, the bille r can ente r a Print Order. Th e Print Or der determ ines the o rder in wh ich the pr ocedures a re arrange d. | |
| 8083 | Storage: | |
| 8084 | File: BILL /CLAIMS (# 399) | |
| 8085 | Subfile: P ROCEDURES (#304) | |
| 8086 | Field: PRI NT ORDER ( 3) | |
| 8087 | ||
| 8088 | 3 | |
| 8089 | Service ID Qualifier | |
| 8090 | 2 A/N | |
| 8091 | 837: (P) 2 400 SV101- 1 | |
| 8092 | Print: N/A | |
| 8093 | Biller Inp ut: Screen 5 Section 4 | |
| 8094 | For each p rocedure o n a claim, the bille r can ente r the codi ng method used. Thi s qualifie r is based on the co ding metho d | |
| 8095 | Storage: N /A | |
| 8096 | Can only u se ER, HC, IV, WK | |
| 8097 | 4 | |
| 8098 | Procedure Code | |
| 8099 | 10 A/N | |
| 8100 | 837: (P) 2 400 SV101 - 2 | |
| 8101 | Print: | |
| 8102 | CMS 1500 – Box 24d | |
| 8103 | Biller Inp ut: | |
| 8104 | Screen 4/5 Section 4 | |
| 8105 | Screen 6/7 Section 5 | |
| 8106 | Storage: | |
| 8107 | File: BILL /CLAIMS (# 399) | |
| 8108 | Subfile: P ROCEDURES (#304) | |
| 8109 | Field: PRO CEDURES (# .01) | |
| 8110 | ||
| 8111 | 5 | |
| 8112 | Line Item Charge Amt | |
| 8113 | 9 N | |
| 8114 | 2 Decimals | |
| 8115 | 837: (P) 2 400 SV102 | |
| 8116 | Print: | |
| 8117 | CMS 1500 – Box 24f | |
| 8118 | Biller Inp ut: Screen 7 Section 5 | |
| 8119 | The system calculate s the char ge amount based on R evenue Cod es, Divisi on and Rea sonable Ch arges. A biller can override the system calculati on if nece ssary. | |
| 8120 | Storage: | |
| 8121 | File: BILL /CLAIMS (# 399) | |
| 8122 | Subfile: R EVENUE COD E (#42) | |
| 8123 | Field: CHA RGES (#.02 ) | |
| 8124 | ||
| 8125 | 6 | |
| 8126 | Service Un it Count | |
| 8127 | 6 N | |
| 8128 | 837: (P) 2 400 SV104 | |
| 8129 | Print: | |
| 8130 | CMS 1500 – Box 24g | |
| 8131 | Biller Inp ut: Screen 7 Section 5 | |
| 8132 | A biller c an change the defaul t value of 1 for the Units of Service. C harges. | |
| 8133 | Storage: | |
| 8134 | File: BILL /CLAIMS (# 399) | |
| 8135 | Subfile: R EVENUE COD E (#42) | |
| 8136 | Field: UNI TS OF SERV ICE (#.03) | |
| 8137 | For Anesth esia: | |
| 8138 | Subfile: P ROCEDURE ( #304) | |
| 8139 | Field: MIN UTES (#15) | |
| 8140 | ||
| 8141 | 7 | |
| 8142 | Place of S ervice Cod e | |
| 8143 | 2 A/N | |
| 8144 | 837: (P) 2 400 SV105 | |
| 8145 | Print: | |
| 8146 | CMS 1500 – Box 24b | |
| 8147 | Biller Inp ut: Screen 5 Section 4 | |
| 8148 | Storage: | |
| 8149 | File: BILL /CLAIMS (# 399) | |
| 8150 | Subfile: P ROCEDURES (#304) | |
| 8151 | Field: PLA CE OF SERV ICE (#8) | |
| 8152 | ||
| 8153 | 8 | |
| 8154 | BLANK | |
| 8155 | 1 | |
| 8156 | ||
| 8157 | ||
| 8158 | ||
| 8159 | 9 | |
| 8160 | Service DT From | |
| 8161 | 8 N CCYYMM DD | |
| 8162 | 837: (P) 2 400 DTP03 (1) | |
| 8163 | Print: | |
| 8164 | CMS 1500 – Box 24a | |
| 8165 | Biller Inp ut: Screen 5 Section 4 | |
| 8166 | Storage: | |
| 8167 | File: BILL /CLAIMS (# 399) | |
| 8168 | Subfile: P ROCEDURES (#304) | |
| 8169 | Field: PRO CEDURE DAT E (#1) | |
| 8170 | ||
| 8171 | 10 | |
| 8172 | Service DT To | |
| 8173 | 8 N | |
| 8174 | CCYYMMDD | |
| 8175 | 837: (P) 2 400 DTP03 (1) | |
| 8176 | Print: | |
| 8177 | CMS 1500 – Box 24a | |
| 8178 | ||
| 8179 | ||
| 8180 | 11 | |
| 8181 | Diagnosis Code Point er (1) | |
| 8182 | 2 A/N | |
| 8183 | 837: (P) 2 400 SV107 - 1 | |
| 8184 | Print: | |
| 8185 | CMS 1500 – Box 24e | |
| 8186 | Biller Inp ut: Screen 5 Section 4 | |
| 8187 | Storage: | |
| 8188 | File: BILL /CLAIMS (# 399) | |
| 8189 | Subfile: P ROCEDURES (#304) | |
| 8190 | Field: ASS OCIATED DI AGNOSIS (1 ) (#10) | |
| 8191 | ||
| 8192 | 12 | |
| 8193 | Diagnosis Code Point er (2) | |
| 8194 | 2 A/N | |
| 8195 | 837: (P) 2 400 SV107 - 2 | |
| 8196 | Print: | |
| 8197 | CMS 1500 – Box 24e | |
| 8198 | Biller Inp ut: Screen 5 Section 4 | |
| 8199 | Storage: | |
| 8200 | File: BILL /CLAIMS (# 399) | |
| 8201 | Subfile: P ROCEDURES (#304) | |
| 8202 | Field: ASS OCIATED DI AGNOSIS (2 ) (#11) | |
| 8203 | ||
| 8204 | 13 | |
| 8205 | Diagnosis Code Point er (3) | |
| 8206 | 2 A/N | |
| 8207 | 837: (P) 2 400 SV107 - 3 | |
| 8208 | Print: | |
| 8209 | CMS 1500 – Box 24e | |
| 8210 | Biller Inp ut: Screen 5 Section 4 | |
| 8211 | Storage: | |
| 8212 | File: BILL /CLAIMS (# 399) | |
| 8213 | Subfile: P ROCEDURES (#304) | |
| 8214 | Field: ASS OCIATED DI AGNOSIS (3 ) (#12) | |
| 8215 | ||
| 8216 | 14 | |
| 8217 | Diagnosis Code Point er (4) | |
| 8218 | 2 A/N | |
| 8219 | 837: (P) 2 400 SV107 - 4 | |
| 8220 | Print: | |
| 8221 | CMS 1500 – Box 24e | |
| 8222 | Biller Inp ut: Screen 5 Section 4 | |
| 8223 | Storage: | |
| 8224 | File: BILL /CLAIMS (# 399) | |
| 8225 | Subfile: P ROCEDURES (#304) | |
| 8226 | Field: ASS OCIATED DI AGNOSIS (4 ) (#13) | |
| 8227 | ||
| 8228 | 15 | |
| 8229 | Procedure Modifier ( 1) | |
| 8230 | 2 N | |
| 8231 | 837: (P) 2 400 SV101 - 3 | |
| 8232 | Print: | |
| 8233 | CMS 1500 – Box 24d | |
| 8234 | Biller Inp ut: Screen 5 Section 4 | |
| 8235 | Storage: | |
| 8236 | File: BILL /CLAIMS (# 399) | |
| 8237 | Subfile: P ROCEDURES (#304) | |
| 8238 | Subfile: C PT MODIFIE R SEQUENCE (#16) | |
| 8239 | Field: CPT MODIFIER (#.01) | |
| 8240 | ||
| 8241 | 16 | |
| 8242 | Procedure Modifier ( 2) | |
| 8243 | 2 N | |
| 8244 | Print: (P) 2400 SV10 1 - 4 | |
| 8245 | Print: | |
| 8246 | CMS 1500 – Box 24d | |
| 8247 | Biller Inp ut: Screen 5 Section 4 | |
| 8248 | Storage: | |
| 8249 | File: BILL /CLAIMS (# 399) | |
| 8250 | Subfile: P ROCEDURES (#304) | |
| 8251 | Subfile: C PT MODIFIE R SEQUENCE (#16) | |
| 8252 | Field: CPT MODIFIER (#.01) | |
| 8253 | ||
| 8254 | 17 | |
| 8255 | Procedure Modifier ( 3) | |
| 8256 | 2 N | |
| 8257 | 837: (P) 2 400 SV101 - 5 | |
| 8258 | Print: | |
| 8259 | CMS 1500 – Box 24d | |
| 8260 | Biller Inp ut: Screen 5 Section 4 | |
| 8261 | Storage: | |
| 8262 | File: BILL /CLAIMS (# 399) | |
| 8263 | Subfile: P ROCEDURES (#304) | |
| 8264 | Subfile: C PT MODIFIE R SEQUENCE (#16) | |
| 8265 | Field: CPT MODIFIER (#.01) | |
| 8266 | ||
| 8267 | 18 | |
| 8268 | Procedure Modifier ( 4) | |
| 8269 | 2 N | |
| 8270 | 837: (P) 2 400 SV101 - 6 | |
| 8271 | Print: | |
| 8272 | CMS 1500 – Box 24d | |
| 8273 | Biller Inp ut: Screen 5 Section 4 | |
| 8274 | Storage: | |
| 8275 | File: BILL /CLAIMS (# 399) | |
| 8276 | Subfile: P ROCEDURES (#304) | |
| 8277 | Subfile: C PT MODIFIE R SEQUENCE (#16) | |
| 8278 | Field: CPT MODIFIER (#.01) | |
| 8279 | ||
| 8280 | 19 | |
| 8281 | Emergency Indicator | |
| 8282 | 1 A | |
| 8283 | (P) 2400 S V109 | |
| 8284 | ||
| 8285 | CMS 1500 – Box 24c | |
| 8286 | Biller Inp ut: Screen 5 Section 4 | |
| 8287 | Storage: | |
| 8288 | File: BILL /CLAIMS (# 399) | |
| 8289 | Subfile: P ROCEDURES (#304) | |
| 8290 | Subfile: C PT MODIFIE R SEQUENCE (#16) | |
| 8291 | Field: CPT MODIFIER (#.01) | |
| 8292 | ||
| 8293 | 20 | |
| 8294 | Units/Basi s for Meas urement Co de | |
| 8295 | 2 A | |
| 8296 | 837: (P) 2 400 SV103 | |
| 8297 | Biller Inp ut: N/A | |
| 8298 | Storage: N /A | |
| 8299 | For Anesth esia – UN | |
| 8300 | All other service ty pes - MJ | |
| 8301 | F2 Deleted / Only us e MJ, UN | |
| 8302 | 21 | |
| 8303 | Service ID Qualifier | |
| 8304 | 2 A/N | |
| 8305 | 837: (P) 2 410 LIN02 | |
| 8306 | Print: N/A | |
| 8307 | Biller Inp ut: N/A | |
| 8308 | Storage: N /A | |
| 8309 | Note: Alwa ys N4 | |
| 8310 | ||
| 8311 | 22 | |
| 8312 | NDC | |
| 8313 | 48 A/N | |
| 8314 | 837: (P) 2 410 LIN03 | |
| 8315 | Print: Box 24 | |
| 8316 | Biller Inp ut: Screen 5 Section 4 | |
| 8317 | Storage: | |
| 8318 | File: BILL /CLAIMS (# 399) | |
| 8319 | Subfile: P ROCEDURES (#304) | |
| 8320 | Field: NDC (#53) | |
| 8321 | ||
| 8322 | 23 | |
| 8323 | National D rug Unit C ount | |
| 8324 | 15 N | |
| 8325 | 837: (P) 2 410 CTP04 | |
| 8326 | Print: Box 24 | |
| 8327 | Biller Inp ut: Screen 5 Section 4 | |
| 8328 | Storage: | |
| 8329 | File BILL/ CLAIMS (#3 99) | |
| 8330 | Subfile: P ROCEDURES (#304) | |
| 8331 | Field: UNI TS (#54) | |
| 8332 | ||
| 8333 | 24 | |
| 8334 | Hospice Em ployee Ind icator | |
| 8335 | 1 A | |
| 8336 | 837: 2400 CRC02 | |
| 8337 | Print: N/A | |
| 8338 | Biller Inp ut: Screen 5 Section 4 | |
| 8339 | Storage: | |
| 8340 | File: BILL /CLAIMS (# 399) | |
| 8341 | Subfile: P ROCEDURES (#304) | |
| 8342 | Field: ATT ENDING NOT HOSPICE E MPLOYEE (# 50.03) | |
| 8343 | CRC01 = 70 CRC03 = 6 5 | |
| 8344 | 25 | |
| 8345 | Unit or Ba sis of Mea surement C ode | |
| 8346 | 2 A | |
| 8347 | 837: (P) 2 410 CTP05- 1 | |
| 8348 | Print: Box 24 | |
| 8349 | Biller Inp ut: Screen 5 Section 4 | |
| 8350 | Storage: N /A | |
| 8351 | Note: Alwa ys UN | |
| 8352 | ||
| 8353 | 26 | |
| 8354 | BLANK | |
| 8355 | 1 | |
| 8356 | ||
| 8357 | ||
| 8358 | ||
| 8359 | 27 | |
| 8360 | BLANK | |
| 8361 | 1 | |
| 8362 | ||
| 8363 | ||
| 8364 | ||
| 8365 | 28 | |
| 8366 | BLANK | |
| 8367 | 1 | |
| 8368 | ||
| 8369 | ||
| 8370 | ||
| 8371 | 29 | |
| 8372 | EPSDT Indi cator | |
| 8373 | 1 A | |
| 8374 | 837: (P) 2 400 SV111 | |
| 8375 | Print: | |
| 8376 | CMS 1500 – Box 24H | |
| 8377 | Biller Inp ut: Screen 5 Section 4 | |
| 8378 | Storage: | |
| 8379 | File: BILL /CLAIMS (# 399) | |
| 8380 | Subfile: P ROCEDURES (#304) | |
| 8381 | Field: EPS DT FLAG (# 50.07) | |
| 8382 | ||
| 8383 | 30 | |
| 8384 | Line Note Text | |
| 8385 | 61 A/N | |
| 8386 | 837: (P) 2 400 NTE02 | |
| 8387 | Print: | |
| 8388 | CMS 1500 – Box 24 ab ove proced ure | |
| 8389 | Biller Inp ut: Screen 5 Section 4 | |
| 8390 | Storage: | |
| 8391 | File: BILL /CLAIMS (# 399) | |
| 8392 | Subfile: P ROCEDURES (#304) | |
| 8393 | Field: SER VICE LINE COMMENT (# 50.08) | |
| 8394 | Field: SER VICE LINE COMMENT QU ALIFIER (# 50.09) | |
| 8395 | NTE01 = AD D. | |
| 8396 | ||
| 8397 | INS - Loop 2400 (Ins titutional Service L ine Data) [SEQ 185] | |
| 8398 | One or mor e records per Claim Data recor d | |
| 8399 | (OPTIONAL – Max leng th 152 byt es) | |
| 8400 | Piece | |
| 8401 | Descriptio n | |
| 8402 | Max Length Data Type | |
| 8403 | 837/Print Location | |
| 8404 | VistA Inpu t/Storage | |
| 8405 | FSC Proces sing Comme nts | |
| 8406 | 1 | |
| 8407 | RECORD ID = ‘INS ’ | |
| 8408 | 4 A | |
| 8409 | ||
| 8410 | ||
| 8411 | ||
| 8412 | 2 | |
| 8413 | Service Li ne Counter | |
| 8414 | 6 N | |
| 8415 | 837: (I) 2 400 LX01 | |
| 8416 | Print: N/A | |
| 8417 | Biller Inp ut: N/A | |
| 8418 | The system will keep track of the order of Revenue Codes and procedure s and keep the corre ct line le vel record s together . | |
| 8419 | Storage: N /A | |
| 8420 | ||
| 8421 | 3 | |
| 8422 | REVENUE CO DE | |
| 8423 | ||
| 8424 | 10 A/N | |
| 8425 | 837: (I) 2 400 SV201 | |
| 8426 | Print: | |
| 8427 | UB04 – FL4 2 | |
| 8428 | Biller Inp ut: Screen 6/7 Secti on 5 | |
| 8429 | The system prepopula tes the Re venue Code s based on Procedure Codes els e users ma y enter Re venue Code s in Secti on 5. | |
| 8430 | File: BILL /CLAIMS (# 399) | |
| 8431 | Subfile: R EVENUE COD ES (#42) | |
| 8432 | Field: REV ENUE CODE (#.01) | |
| 8433 | ||
| 8434 | 4 | |
| 8435 | Procedure Code | |
| 8436 | ||
| 8437 | 10 A/N | |
| 8438 | 837: (I) 2 400 SV202 - 2 | |
| 8439 | Print: | |
| 8440 | UB04 – FL 44 | |
| 8441 | Biller Inp ut: | |
| 8442 | Screen 4/5 Section 4 | |
| 8443 | Screen 6/7 Section 5 | |
| 8444 | Storage: | |
| 8445 | File: BILL /CLAIMS (# 399) | |
| 8446 | Subfile: P ROCEDURES (#304) | |
| 8447 | Field: PRO CEDURES (# .01) | |
| 8448 | Set SV202 – 1 = HC | |
| 8449 | 5 | |
| 8450 | Service Un it Count | |
| 8451 | 6 N | |
| 8452 | 837: (I) 2 400 SV205 | |
| 8453 | Print: | |
| 8454 | UB04 – FL 46 | |
| 8455 | Biller Inp ut: Screen 6/7 Secti on 5 | |
| 8456 | The system calculate s the char ge amount based on R evenue Cod es, Divisi on and Rea sonable Ch arges. A biller can override the system calculati on if nece ssary. | |
| 8457 | Storage: | |
| 8458 | File: BILL /CLAIMS (# 399) | |
| 8459 | Subfile: R EVENUE COD E (#42) | |
| 8460 | Field: CHA RGES (#.02 ) | |
| 8461 | ||
| 8462 | 6 | |
| 8463 | BLANK | |
| 8464 | 1 | |
| 8465 | ||
| 8466 | ||
| 8467 | ||
| 8468 | 7 | |
| 8469 | Procedure Modifier ( 1) | |
| 8470 | ||
| 8471 | 2 A/N | |
| 8472 | 837: (I) 2 400 SV202 – 3 | |
| 8473 | Print: | |
| 8474 | UB04 – FL4 4 | |
| 8475 | Biller Inp ut: Scree n 5 Sectio n 4 | |
| 8476 | Storage: | |
| 8477 | File: BILL /CLAIMS (# 399) | |
| 8478 | Subfile: P PROCEDURES (#304) | |
| 8479 | Subfile: C PT MODIFIE R SEQUENCE (#16) | |
| 8480 | Field: CPT MODIFIER (#.02) | |
| 8481 | ||
| 8482 | 8 | |
| 8483 | Procedure Modifier ( 2) | |
| 8484 | ||
| 8485 | 2 A/N | |
| 8486 | 837: (I) 2 400 SV202 – 4 | |
| 8487 | Print: | |
| 8488 | UB04 – FL4 4 | |
| 8489 | Biller Inp ut: Scree n 5 Sectio n 4 | |
| 8490 | Storage: | |
| 8491 | File: BILL /CLAIMS (# 399) | |
| 8492 | Subfile: P PROCEDURES (#304) | |
| 8493 | Subfile: C PT MODIFIE R SEQUENCE (#16) | |
| 8494 | Field: CPT MODIFIER (#.02) | |
| 8495 | ||
| 8496 | 9 | |
| 8497 | Service Li ne Charge Amt | |
| 8498 | 18 N | |
| 8499 | 2 Decimals | |
| 8500 | 837: (I) 2 400 SV203 | |
| 8501 | Print: | |
| 8502 | UB04 – FL 47 | |
| 8503 | Biller Inp ut: Screen 6/7 Secti on 5 | |
| 8504 | The system calculate s the char ge amount based on R evenue Cod es, Divisi on and Rea sonable Ch arges. A biller can override the system calculati on if nece ssary. | |
| 8505 | Storage: | |
| 8506 | File: BILL /CLAIMS (# 399) | |
| 8507 | Subfile: R EVENUE COD E (#42) | |
| 8508 | Field: CHA RGES (#.02 ) | |
| 8509 | ||
| 8510 | 10 | |
| 8511 | Service Da te From | |
| 8512 | 8 N CCYYMM DD | |
| 8513 | Print: (I) 2400 DTP0 3 | |
| 8514 | Print: N/A | |
| 8515 | ||
| 8516 | Biller Inp ut: | |
| 8517 | Screen 4/5 Section 4 | |
| 8518 | Screen 6/7 Section 5 | |
| 8519 | Storage: | |
| 8520 | File: BILL /CLAIMS (# 399) | |
| 8521 | Subfile: P ROCEDURES (#304) | |
| 8522 | Field: PRO CEDURE DAT E (#1) | |
| 8523 | Set DTP01 = 472 | |
| 8524 | DTP02 = D8 | |
| 8525 | 11 | |
| 8526 | BLANK | |
| 8527 | 1 | |
| 8528 | ||
| 8529 | ||
| 8530 | ||
| 8531 | 12 | |
| 8532 | Service Li ne Non-Cov ered Charg e Amt | |
| 8533 | 18 N | |
| 8534 | 2 Decimals | |
| 8535 | 837: (I) 2 400 SV207 | |
| 8536 | Print: | |
| 8537 | UB04 – FL4 8 | |
| 8538 | Biller Inp ut: Screen 6/7 Secti on 5 | |
| 8539 | Storage: | |
| 8540 | File: BILL /CLAIMS (# 399) | |
| 8541 | Subfile: R EVENUE COD E (#42) | |
| 8542 | Field: NON -COVERED C HARGE (#.0 9) | |
| 8543 | ||
| 8544 | 13 | |
| 8545 | Units/Basi s for Meas urement Co de | |
| 8546 | 2 A | |
| 8547 | 837: (I) 2 400 SV204 | |
| 8548 | Print: N/A | |
| 8549 | Biller Inp ut: N/A | |
| 8550 | Storage: N /A | |
| 8551 | Note: Alwa ys DA for 100-219 | |
| 8552 | Always UN for all ot her Proced ures | |
| 8553 | F2 Deleted / Only us e DA, UN | |
| 8554 | 14 | |
| 8555 | Service ID Qualifier | |
| 8556 | 2 A/N | |
| 8557 | 837: (I) 2 410 LIN02 | |
| 8558 | Print: N/A | |
| 8559 | Biller Inp ut: N/A | |
| 8560 | Storage: N /A | |
| 8561 | Note: Alwa ys N4 | |
| 8562 | ||
| 8563 | 15 | |
| 8564 | NDC | |
| 8565 | 48 A/N | |
| 8566 | 837: (I) 2 410 LIN03 | |
| 8567 | Print: FL8 0 | |
| 8568 | Biller Inp ut: Screen 4/5 Secti on 4 | |
| 8569 | Storage: | |
| 8570 | File: BILL /CLAIMS (# 399) | |
| 8571 | Subfile: P ROCEDURES (#304) | |
| 8572 | Field: NDC (#53) | |
| 8573 | ||
| 8574 | 16 | |
| 8575 | National D rug Unit C ount | |
| 8576 | 15 N | |
| 8577 | 837: (I) 2 410 CTP04 | |
| 8578 | Print: FL8 0 | |
| 8579 | Biller Inp ut: Screen 5 Section 4 | |
| 8580 | Storage: | |
| 8581 | File BILL/ CLAIMS (#3 99) | |
| 8582 | Subfile: P ROCEDURES (#304) | |
| 8583 | Field: UNI TS (#54) | |
| 8584 | ||
| 8585 | 17 | |
| 8586 | Unit or Ba sis of Mea surement C ode | |
| 8587 | 2 A | |
| 8588 | 837: (I) 2 410 CTP05- 1 | |
| 8589 | Print: FL8 0 | |
| 8590 | Biller Inp ut: Screen 5 Section 4 | |
| 8591 | Storage: N /A | |
| 8592 | Note: Alwa ys UN | |
| 8593 | ||
| 8594 | ||
| 8595 | ||
| 8596 | RX1 - Loop 2400/2410 (Drug Ser vice Line Data) [SEQ 190] | |
| 8597 | One or mor e records per Claim Data recor d | |
| 8598 | (OPTIONAL – Max leng th 135 by tes) | |
| 8599 | Piece | |
| 8600 | Descriptio n | |
| 8601 | Max Length Data Type | |
| 8602 | 837/Print Location | |
| 8603 | VistA Inpu t/Storage | |
| 8604 | FSC Proces sing Comme nts | |
| 8605 | 1 | |
| 8606 | RECORD ID = ‘RX1 ’ | |
| 8607 | 4 A | |
| 8608 | ||
| 8609 | ||
| 8610 | ||
| 8611 | 2 | |
| 8612 | Service Li ne Counter | |
| 8613 | 6 N | |
| 8614 | 837: (P) 2 400 LX01 | |
| 8615 | Print: N/A | |
| 8616 | Biller Inp ut: N/A | |
| 8617 | The system will keep track of the order of Revenue Codes and procedure s and keep the corre ct line le vel record s together . | |
| 8618 | Storage: N /A | |
| 8619 | ||
| 8620 | 3 | |
| 8621 | Prescripti on # | |
| 8622 | 15 A/N | |
| 8623 | 837: (P) 2 410 REF02 | |
| 8624 | Print: | |
| 8625 | CMS 1500 – Box 24 | |
| 8626 | Biller Inp ut: Screen 5 Section 5 | |
| 8627 | Billers ca n add an R X to a cla im. The a ctual RX c omes from the Pharma cy softwar e. Billers can overr ide the da ta from th e pharmacy . | |
| 8628 | Storage: | |
| 8629 | File: BILL /CLAIMS PR ESCRIPTION REFILL (# 362.4) | |
| 8630 | Field: RX # (#.01) | |
| 8631 | VY code ha s been inc luded in R EF01 eleme nt. | |
| 8632 | Max HIPAA length inc reased to 50. | |
| 8633 | 4 | |
| 8634 | National D rug Code ( 1) | |
| 8635 | 11 A/N | |
| 8636 | 837: (P) 2 410 LIN03 (1) | |
| 8637 | Print: | |
| 8638 | CMS 1500 – Box 24 | |
| 8639 | Biller Inp ut: Screen 5 Section 5 | |
| 8640 | Billers ca n add an R X to a cla im. The a ctual RX c omes from the Pharma cy softwar e. Billers can overr ide the da ta from th e pharmacy . | |
| 8641 | Storage: | |
| 8642 | File: BILL /CLAIMS PR ESCRIPTION REFILL (# 362.4) | |
| 8643 | Field: NDC # (#.08) | |
| 8644 | ||
| 8645 | 5 | |
| 8646 | BLANK | |
| 8647 | 1 | |
| 8648 | ||
| 8649 | ||
| 8650 | ||
| 8651 | 6 | |
| 8652 | Quantity, Days Suppl y | |
| 8653 | 55 A/N | |
| 8654 | 837: (P) 2 400 SV101 – 7 | |
| 8655 | Print: | |
| 8656 | CMS 1500 – Box 24 | |
| 8657 | Biller Inp ut: Screen 5 Section 5 | |
| 8658 | Billers ca n add an R X to a cla im. The a ctual RX c omes from the Pharma cy softwar e. Billers can overr ide the da ta from th e pharmacy . | |
| 8659 | Storage: | |
| 8660 | File: BILL /CLAIMS PR ESCRIPTION REFILL (# 362.4) | |
| 8661 | Field: DAY S SUPPLY ( #.06) | |
| 8662 | ||
| 8663 | 7 | |
| 8664 | Service Da te (Refill ) | |
| 8665 | 8 N CCYYMM DD | |
| 8666 | 837: (P) 2 400 DTP03 (1) | |
| 8667 | Print: N/A | |
| 8668 | ||
| 8669 | ||
| 8670 | Biller Inp ut: Screen 5 Section 5 | |
| 8671 | Billers ca n add an R X to a cla im. The a ctual RX c omes from the Pharma cy softwar e. Billers can overr ide the da ta from th e pharmacy . | |
| 8672 | Storage: | |
| 8673 | File: BILL /CLAIMS PR ESCRIPTION REFILL (# 362.4) | |
| 8674 | Field: DAT E (#.03) | |
| 8675 | Set DTP01 = 472 DTP0 2 = D8. | |
| 8676 | 8 | |
| 8677 | National D rug Unit C ount | |
| 8678 | 10 N | |
| 8679 | 837: (P) 2 410 CTP04 | |
| 8680 | ||
| 8681 | CMS 1500 – Box 24 | |
| 8682 | Biller Inp ut: Screen 5 Section 5 | |
| 8683 | Billers ca n add an R X to a cla im. The a ctual RX c omes from the Pharma cy softwar e. Billers can overr ide the da ta from th e pharmacy . | |
| 8684 | Storage: | |
| 8685 | File: BILL /CLAIMS PR ESCRIPTION REFILL (# 362.4) | |
| 8686 | Field: QTY (#.07) | |
| 8687 | Set CTP05- 1 = UN. | |
| 8688 | 9 | |
| 8689 | BLANK | |
| 8690 | 1 | |
| 8691 | ||
| 8692 | ||
| 8693 | ||
| 8694 | 10 | |
| 8695 | Service ID Qualifier | |
| 8696 | ||
| 8697 | 2 A/N | |
| 8698 | 837: (P) 2 410 LIN02 | |
| 8699 | Print: | |
| 8700 | CMS 1500 – Box 24 | |
| 8701 | Biller Inp ut: N/A | |
| 8702 | Storage: N /A | |
| 8703 | Always: N4 - NDC in 5-4-2 Form at | |
| 8704 | ||
| 8705 | 11 | |
| 8706 | Prescripti on Date Qu alifier | |
| 8707 | 3 N | |
| 8708 | 837: (P) D TP01 | |
| 8709 | Print: N/A | |
| 8710 | Biller Inp ut: N/A | |
| 8711 | Storage: N /A | |
| 8712 | Note: Alwa ys 471 | |
| 8713 | ||
| 8714 | 12 | |
| 8715 | Prescripti on Date | |
| 8716 | 8 N CCYYMM DD | |
| 8717 | 837: (P) 2 400 DTP03 | |
| 8718 | Print: N/A | |
| 8719 | Biller Inp ut: Screen 5 Section 5 | |
| 8720 | Billers ca n add an R X to a cla im. The a ctual RX c omes from the Pharma cy softwar e. Billers can overr ide the da ta from th e pharmacy . | |
| 8721 | Storage: | |
| 8722 | File: BILL /CLAIMS PR ESCRIPTION REFILL (# 362.4) | |
| 8723 | Field: ORD ER DATE (# .11) | |
| 8724 | DTP02 = D8 | |
| 8725 | ||
| 8726 | LDAT – Loo p 2400 Sup plemental line infor mation [SE Q 191] | |
| 8727 | One per IN S or PRF s egment | |
| 8728 | (OPTIONAL – Max leng th 199 byt es) | |
| 8729 | Piece | |
| 8730 | Descriptio n | |
| 8731 | Max Length Data Type | |
| 8732 | 837/Print Location | |
| 8733 | VistA Inpu t/Storage | |
| 8734 | FSC Proces sing Comme nts | |
| 8735 | 1 | |
| 8736 | RECORD ID = ‘LDAT ’ | |
| 8737 | 4 A | |
| 8738 | ||
| 8739 | ||
| 8740 | ||
| 8741 | 2 | |
| 8742 | Service Li ne Counter | |
| 8743 | 6 N | |
| 8744 | 837: 2400 LX01 | |
| 8745 | Print: N/A | |
| 8746 | Biller Inp ut: N/A | |
| 8747 | The system will keep track of the order of Revenue Codes and procedure s and keep the corre ct line le vel record s together . | |
| 8748 | Storage: N /A | |
| 8749 | ||
| 8750 | 3 | |
| 8751 | Attachment Report Ty pe | |
| 8752 | 2 A | |
| 8753 | 837: 2400 PWK01 | |
| 8754 | Print: | |
| 8755 | CMS 1500 – Box 19 (W orker’s Co mp. claims ) | |
| 8756 | Biller Inp ut: Screen 4/5 Secti on 4 | |
| 8757 | Storage: | |
| 8758 | File: BILL /CLAIMS (# 399) | |
| 8759 | Subfile: P ROCEDURES (#304) | |
| 8760 | Field: ATT ACHMENT RE PORT TYPE (#71) | |
| 8761 | ||
| 8762 | 4 | |
| 8763 | Attachment Report Tr ansmission Code | |
| 8764 | 2 A | |
| 8765 | 837: 2400 PWK02 | |
| 8766 | Print: | |
| 8767 | CMS 1500 – Box 19 (W orker’s Co mp. claims ) | |
| 8768 | Biller Inp ut: Screen 4/5 Secti on 4 | |
| 8769 | Storage: | |
| 8770 | File: BILL /CLAIMS (# 399) | |
| 8771 | Subfile: P ROCEDURES (#304) | |
| 8772 | Field: ATT ACHMENT RE PORT TRANS CODE (#7 2) | |
| 8773 | ||
| 8774 | 5 | |
| 8775 | Attachment Control Q ualifier | |
| 8776 | 2 A | |
| 8777 | 837: 2400 PWK05 | |
| 8778 | Print: N/A | |
| 8779 | Biller Inp ut: N/A | |
| 8780 | Storage: N /A | |
| 8781 | Note: Alwa ys AC | |
| 8782 | ||
| 8783 | 6 | |
| 8784 | Attachment Control N umber | |
| 8785 | 30 A/N | |
| 8786 | 837: 2400 PWK06 | |
| 8787 | Print: | |
| 8788 | CMS 1500 – Box 19 (W orkman’s C omp. claim s) | |
| 8789 | Biller Inp ut: Screen 4/5 Secti on 4 | |
| 8790 | Storage: | |
| 8791 | File: BILL /CLAIMS (# 399) | |
| 8792 | Subfile: P ROCEDURES (#304) | |
| 8793 | Field: ATT ACHMENT CO NTROL NUMB ER (#70) | |
| 8794 | ||
| 8795 | 7 | |
| 8796 | OB Anesthe sia Additi onal Unit s Qualifie r | |
| 8797 | 2 A | |
| 8798 | 837: (P)24 00 QTY01 | |
| 8799 | Print: N/A | |
| 8800 | Biller Inp ut: N/A | |
| 8801 | Storage: N /A | |
| 8802 | Note: Alwa ys FL | |
| 8803 | ||
| 8804 | 8 | |
| 8805 | OB Anesthe sia Additi onal Units | |
| 8806 | 5 N | |
| 8807 | 837: (P)24 00 QTY02 | |
| 8808 | Print: N/A | |
| 8809 | Biller Inp ut: Screen 4/5 Secti on 4 | |
| 8810 | Storage: | |
| 8811 | File: BILL /CLAIMS (# 399) | |
| 8812 | Subfile: P ROCEDURES (#304) | |
| 8813 | Field: ADD ITIONAL OB MINUTES ( #74) | |
| 8814 | ||
| 8815 | 9 | |
| 8816 | BLANK | |
| 8817 | 1 | |
| 8818 | ||
| 8819 | ||
| 8820 | ||
| 8821 | 10 | |
| 8822 | BLANK | |
| 8823 | 1 | |
| 8824 | ||
| 8825 | ||
| 8826 | ||
| 8827 | 11 | |
| 8828 | Line Item Control Nu mber Quali fier | |
| 8829 | 2 A/N | |
| 8830 | 837: 2400 REF01 | |
| 8831 | Print: N/A | |
| 8832 | Biller Inp ut: N/A | |
| 8833 | Storage: N /A | |
| 8834 | Note: Alwa ys 6R | |
| 8835 | ||
| 8836 | 12 | |
| 8837 | Line Item Control Nu mber | |
| 8838 | 20 A/N | |
| 8839 | 837: 2400 REF02 | |
| 8840 | Print: N/A | |
| 8841 | Biller Inp ut: N/A | |
| 8842 | The system creates t his number from the sequence o f the line item and the claim number –Ex ample: 1_K 101XXX | |
| 8843 | Storage: N /A | |
| 8844 | Value shou ld be retu rned on 83 5 | |
| 8845 | 13 | |
| 8846 | Purchase S ervice Pro vider ID | |
| 8847 | 20 A/N | |
| 8848 | 837: 2400 PS101 | |
| 8849 | Print: N/A | |
| 8850 | Biller Inp ut: Screen 4/5 Secti on 4 | |
| 8851 | Billers ca n add line level pro viders to a claim bu t the NPI comes from the New P erson file or the IB Non-/Othe r VA Billi ng Provide r file | |
| 8852 | Storage: | |
| 8853 | File: NEW PERSON (#2 00) | |
| 8854 | Field: NPI (#41.99) | |
| 8855 | File: IB N ON/OTHER B ILLING PRO VIDER (#35 5.93) | |
| 8856 | Field: NPI (#41.01) | |
| 8857 | Should equ al a provi der from 2 420 loop e ither NM10 9 or REF02 | |
| 8858 | 14 | |
| 8859 | Purchase S ervice Amo unt | |
| 8860 | 8 N | |
| 8861 | 2 Decimals | |
| 8862 | 837: 2400 PS102 | |
| 8863 | Print: N/A | |
| 8864 | Biller Inp ut: Screen 4/5 Secti on 4 | |
| 8865 | Storage: | |
| 8866 | File: BILL /CLAIMS (# 399) | |
| 8867 | Subfile: P ROCEDURES (#304) | |
| 8868 | Subfile: L INE PROVID ER (#60) | |
| 8869 | Field: PUR CHASED COS T (#19) | |
| 8870 | ||
| 8871 | 15 | |
| 8872 | Descriptio n (NOC Pro cedure) | |
| 8873 | 80 A/N | |
| 8874 | 837: | |
| 8875 | (P) 2400 S V101-7 | |
| 8876 | (I) 2400 S V202-7 | |
| 8877 | Print: N/A | |
| 8878 | Biller Inp ut: Screen 4/5 Secti on 4 | |
| 8879 | Storage: | |
| 8880 | File: BILL /CLAIMS (# 399) | |
| 8881 | Subfile: P ROCEDURES (#304) | |
| 8882 | Field: PRO CEDURE DES CRIPTION ( #51) | |
| 8883 | ||
| 8884 | ||
| 8885 | LOPE - Loo p 2420A (L ine Operat ing Physic ian Data) [SEQ 192] | |
| 8886 | (Max one r ecord per Line | |
| 8887 | (OPTIONAL – Max len gth 180 by tes) | |
| 8888 | Piece | |
| 8889 | Descriptio n | |
| 8890 | Max Length Data Type | |
| 8891 | 837/Print Location | |
| 8892 | VistA Inpu t/Storage | |
| 8893 | FSC Proces sing Comme nts | |
| 8894 | 1 | |
| 8895 | RECORD ID = ‘LOPE’ | |
| 8896 | 4 A | |
| 8897 | ||
| 8898 | ||
| 8899 | ||
| 8900 | 2 | |
| 8901 | Service Li ne Counter | |
| 8902 | 6 N | |
| 8903 | 837: (I) 2 400 LX01 | |
| 8904 | Print: N/A | |
| 8905 | Biller Inp ut: N/A | |
| 8906 | The system will keep track of the order of Revenue Codes and procedure s and keep the corre ct line le vel record s together . | |
| 8907 | Storage: N /A | |
| 8908 | ||
| 8909 | 3 | |
| 8910 | Operating Physician Qualifier | |
| 8911 | 2 N | |
| 8912 | 837: (I)24 20A NM101 | |
| 8913 | Print: N/A | |
| 8914 | Biller Inp ut: N/A | |
| 8915 | Storage: N /A | |
| 8916 | Note: Alwa ys 72 | |
| 8917 | ||
| 8918 | 4 | |
| 8919 | Operating Physician Last Name | |
| 8920 | 60 A | |
| 8921 | 837: (I)24 20A NM103 | |
| 8922 | Print: N/A | |
| 8923 | Biller Inp ut: | |
| 8924 | Screen 4/5 Section 4 | |
| 8925 | Storage: | |
| 8926 | File: BILL /CLAIMS (# 399) | |
| 8927 | Subfile: P ROCEDURES (#304) | |
| 8928 | Subfile: L INE PROVID ER (#60) | |
| 8929 | Field: LIN E PERFORME D BY (#.02 ) | |
| 8930 | NM102 = 1 | |
| 8931 | 5 | |
| 8932 | Operating Physician First Name | |
| 8933 | 35 A | |
| 8934 | 837: (I) 2 420A NM104 | |
| 8935 | Print: N/A | |
| 8936 | Biller Inp ut: | |
| 8937 | Screen 4/5 Section 4 | |
| 8938 | Storage: | |
| 8939 | File: BILL /CLAIMS (# 399) | |
| 8940 | Subfile: P ROCEDURES (#304) | |
| 8941 | Subfile: L INE PROVID ER (#60) | |
| 8942 | Field: LIN E PERFORME D BY (#.02 ) | |
| 8943 | ||
| 8944 | 6 | |
| 8945 | Operating Physician Middle | |
| 8946 | 1 A | |
| 8947 | 837: (I) 2 420A NM105 | |
| 8948 | Print: N/A | |
| 8949 | Biller Inp ut: | |
| 8950 | Screen 4/5 Section 4 | |
| 8951 | Storage: | |
| 8952 | File: BILL /CLAIMS (# 399) | |
| 8953 | Subfile: P ROCEDURES (#304) | |
| 8954 | Subfile: L INE PROVID ER (#60) | |
| 8955 | Field: LIN E PERFORME D BY (#.02 ) | |
| 8956 | ||
| 8957 | 7 | |
| 8958 | Operating Physician Name Suffi x | |
| 8959 | 10 A | |
| 8960 | 837: (I) 2 420A NM107 | |
| 8961 | Print: N/A | |
| 8962 | Biller Inp ut: | |
| 8963 | Screen 4/5 Section 4 | |
| 8964 | Storage: | |
| 8965 | File: BILL /CLAIMS (# 399) | |
| 8966 | Subfile: P ROCEDURES (#304) | |
| 8967 | Subfile: L INE PROVID ER (#60) | |
| 8968 | Field: LIN E PERFORME D BY (#.02 ) | |
| 8969 | ||
| 8970 | 8 | |
| 8971 | Operating Physician Primary ID Qualifier | |
| 8972 | 2 A | |
| 8973 | 837: (I) 2 420A NM108 | |
| 8974 | Print: N/A | |
| 8975 | Biller Inp ut: N/A | |
| 8976 | Storage: N /A | |
| 8977 | Note: Alwa ys XX | |
| 8978 | ||
| 8979 | 9 | |
| 8980 | Operating Physician Primary ID | |
| 8981 | 10 N | |
| 8982 | 837: (I) 2 420A NM109 | |
| 8983 | Print: N/A | |
| 8984 | Biller Inp ut: N/A | |
| 8985 | The biller can add a provider to a claim but the p rovider’s NPI comes from the N ew Person file. | |
| 8986 | Storage: | |
| 8987 | File: NEW PERSON (#2 00) | |
| 8988 | Field: NPI (#41.99) | |
| 8989 | ||
| 8990 | 10 | |
| 8991 | Operating Physician Secondary ID Qualifi er (1) | |
| 8992 | 2 A/N | |
| 8993 | 837: (I) 2 420A REF01 | |
| 8994 | Print: N/A | |
| 8995 | Biller Inp ut: Screen 5 Section 4 | |
| 8996 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 8997 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 8998 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 8999 | Storage: | |
| 9000 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9001 | Or by Care Unit | |
| 9002 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9003 | Field: PRO VIDER ID T YPE (#.06) | |
| 9004 | Code set: 0B, 1G, G2 , LU | |
| 9005 | 11 | |
| 9006 | Operating Physician Secondary ID(1) | |
| 9007 | 10 A/N | |
| 9008 | 837: (I) 2 420A REF02 | |
| 9009 | Print: N/A | |
| 9010 | Biller Inp ut: Screen 5 Section 4 | |
| 9011 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9012 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9013 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9014 | Storage: | |
| 9015 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9016 | Or by Care Unit | |
| 9017 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9018 | Field: PRO VIDER ID ( #.07) | |
| 9019 | ||
| 9020 | 12 | |
| 9021 | Operating Physician Secondary ID Qualifi er (2) | |
| 9022 | 2 A/N | |
| 9023 | 837: (I) 2 420A REF01 | |
| 9024 | Print: N/A | |
| 9025 | Biller Inp ut: Screen 5 Section 4 | |
| 9026 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9027 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9028 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9029 | Storage: | |
| 9030 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9031 | Or by Care Unit | |
| 9032 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9033 | Field: PRO VIDER ID T YPE (#.06) | |
| 9034 | Code set: 0B, 1G, G2 , LU | |
| 9035 | 13 | |
| 9036 | Operating Physician Secondary ID(2) | |
| 9037 | 10 A/N | |
| 9038 | 837: (I) 2 420A REF02 | |
| 9039 | Print: N/A | |
| 9040 | Biller Inp ut: Screen 5 Section 4 | |
| 9041 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9042 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9043 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9044 | Storage: | |
| 9045 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9046 | Or by Care Unit | |
| 9047 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9048 | Field: PRO VIDER ID ( #.07) | |
| 9049 | ||
| 9050 | 14 | |
| 9051 | Operating Physician Secondary ID Qualifi er (3) | |
| 9052 | 2 A/N | |
| 9053 | 837: (I) 2 420A REF01 | |
| 9054 | Print: N/A | |
| 9055 | Biller Inp ut: Screen 5 Section 4 | |
| 9056 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9057 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9058 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9059 | Storage: | |
| 9060 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9061 | Or by Care Unit | |
| 9062 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9063 | Field: PRO VIDER ID T YPE (#.06) | |
| 9064 | Code set: 0B, 1G, G2 , LU | |
| 9065 | 15 | |
| 9066 | Operating Physician Secondary ID(3) | |
| 9067 | 10 A/N | |
| 9068 | 837: (I) 2 420A REF02 | |
| 9069 | Print: N/A | |
| 9070 | Biller Inp ut: Screen 5 Section 4 | |
| 9071 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9072 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9073 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9074 | Storage: | |
| 9075 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9076 | Or by Care Unit | |
| 9077 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9078 | Field: PRO VIDER ID ( #.07) | |
| 9079 | ||
| 9080 | ||
| 9081 | ||
| 9082 | LOP1 - Loo p 2420B (L ine Other Operating Physician Data) [SE Q 193] | |
| 9083 | Maximum on e record p er Line | |
| 9084 | (OPTIONAL – Max len gth 180 by tes) | |
| 9085 | Piece | |
| 9086 | Descriptio n | |
| 9087 | Max Length Data Type | |
| 9088 | 837/Print Location | |
| 9089 | VistA Inpu t/Storage | |
| 9090 | FSC Proces sing Comme nts | |
| 9091 | 1 | |
| 9092 | RECORD ID = ‘LOP1’ | |
| 9093 | 4 A | |
| 9094 | ||
| 9095 | ||
| 9096 | ||
| 9097 | 2 | |
| 9098 | Service Li ne Counter | |
| 9099 | 6 N | |
| 9100 | 837: (I) 2 400 LX01 | |
| 9101 | Print: N/A | |
| 9102 | Biller Inp ut: N/A | |
| 9103 | The system will keep track of the order of Revenue Codes and procedure s and keep the corre ct line le vel record s together . | |
| 9104 | Storage: N /A | |
| 9105 | ||
| 9106 | 3 | |
| 9107 | Other Oper ating Qual ifier | |
| 9108 | 2 A | |
| 9109 | 837: (I)24 20B NM101 | |
| 9110 | Print: N/A | |
| 9111 | Biller Inp ut: N/A | |
| 9112 | Storage: N /A | |
| 9113 | Note: Alwa ys ZZ | |
| 9114 | ||
| 9115 | 4 | |
| 9116 | Other Oper ating Prov ider Last Name | |
| 9117 | 60 A | |
| 9118 | 837: (I)24 20B NM103 | |
| 9119 | Print: N/A | |
| 9120 | Biller Inp ut: | |
| 9121 | Screen 4/5 Section 4 | |
| 9122 | Storage: | |
| 9123 | File: BILL /CLAIMS (# 399) | |
| 9124 | Subfile: P ROCEDURES (#304) | |
| 9125 | Subfile: L INE PROVID ER (#60) | |
| 9126 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9127 | NM102 = 1 | |
| 9128 | 5 | |
| 9129 | Other Oper ating Prov ider First Name | |
| 9130 | 35 A | |
| 9131 | 837: (I) 2 420B NM104 | |
| 9132 | Print: N/A | |
| 9133 | Biller Inp ut: | |
| 9134 | Screen 4/5 Section 4 | |
| 9135 | Storage: | |
| 9136 | File: BILL /CLAIMS (# 399) | |
| 9137 | Subfile: P ROCEDURES (#304) | |
| 9138 | Subfile: L INE PROVID ER (#60) | |
| 9139 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9140 | ||
| 9141 | 6 | |
| 9142 | Other Oper ating Prov ider Middl e | |
| 9143 | 1 A | |
| 9144 | 837: (I) 2 420B NM105 | |
| 9145 | Print: N/A | |
| 9146 | Biller Inp ut: | |
| 9147 | Screen 4/5 Section 4 | |
| 9148 | Storage: | |
| 9149 | File: BILL /CLAIMS (# 399) | |
| 9150 | Subfile: P ROCEDURES (#304) | |
| 9151 | Subfile: L INE PROVID ER (#60) | |
| 9152 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9153 | ||
| 9154 | 7 | |
| 9155 | Other Oper ating Prov ider Name Suffix | |
| 9156 | 10 A | |
| 9157 | 837: (I) 2 420B NM107 | |
| 9158 | Print: N/A | |
| 9159 | Biller Inp ut: | |
| 9160 | Screen 4/5 Section 4 | |
| 9161 | Storage: | |
| 9162 | File: BILL /CLAIMS (# 399) | |
| 9163 | Subfile: P ROCEDURES (#304) | |
| 9164 | Subfile: L INE PROVID ER (#60) | |
| 9165 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9166 | ||
| 9167 | 8 | |
| 9168 | Other Oper ating Prov ider Prima ry ID Qual ifier | |
| 9169 | 2 A | |
| 9170 | 837: (I) 2 420B NM108 | |
| 9171 | Print: N/A | |
| 9172 | Biller Inp ut: N/A | |
| 9173 | Storage: N /A | |
| 9174 | Note: Alwa ys XX | |
| 9175 | ||
| 9176 | 9 | |
| 9177 | Other Oper ating Prov ider Prima ry ID | |
| 9178 | 10 N | |
| 9179 | 837: (I) 2 420B NM109 | |
| 9180 | Print: N/A | |
| 9181 | Biller Inp ut: N/A | |
| 9182 | The biller can add a provider to a claim but the p rovider’s NPI comes from the N ew Person file. | |
| 9183 | Storage: | |
| 9184 | File: NEW PERSON (#2 00) | |
| 9185 | Field: NPI (#41.99) | |
| 9186 | ||
| 9187 | 10 | |
| 9188 | Other Oper ating Prov ider Secon dary ID Qu alifier (1 ) | |
| 9189 | 2 A/N | |
| 9190 | 837: (I) 2 420B REF01 | |
| 9191 | Print: N/A | |
| 9192 | Biller Inp ut: Screen 5 Section 4 | |
| 9193 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9194 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9195 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9196 | Storage: | |
| 9197 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9198 | Or by Care Unit | |
| 9199 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9200 | Field: PRO VIDER ID T YPE (#.06) | |
| 9201 | Code set: 0B, 1G, G2 , LU | |
| 9202 | 11 | |
| 9203 | Other Oper ating Prov ider Secon dary ID(1) | |
| 9204 | 10 A/N | |
| 9205 | 837: (I) 2 420B REF02 | |
| 9206 | Print: N/A | |
| 9207 | Biller Inp ut: Screen 5 Section 4 | |
| 9208 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9209 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9210 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9211 | Storage: | |
| 9212 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9213 | Or by Care Unit | |
| 9214 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9215 | Field: PRO VIDER ID ( #.07) | |
| 9216 | ||
| 9217 | 12 | |
| 9218 | Other Oper ating Prov ider Secon dary ID Qu alifier (2 ) | |
| 9219 | 2 A/N | |
| 9220 | 837: (I) 2 420B REF01 | |
| 9221 | Print: N/A | |
| 9222 | Biller Inp ut: Screen 5 Section 4 | |
| 9223 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9224 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9225 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9226 | Storage: | |
| 9227 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9228 | Or by Care Unit | |
| 9229 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9230 | Field: PRO VIDER ID T YPE (#.06) | |
| 9231 | Code set: 0B, 1G, G2 , LU | |
| 9232 | 13 | |
| 9233 | Other Oper ating Prov ider Secon dary ID(2) | |
| 9234 | 10 A/N | |
| 9235 | 837: (I) 2 420B REF02 | |
| 9236 | Print: N/A | |
| 9237 | Biller Inp ut: Screen 5 Sectio n 4 | |
| 9238 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9239 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9240 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9241 | Storage: | |
| 9242 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9243 | Or by Care Unit | |
| 9244 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9245 | Field: PRO VIDER ID ( #.07) | |
| 9246 | ||
| 9247 | 14 | |
| 9248 | Other Oper ating Prov ider Secon dary ID Qu alifier (3 ) | |
| 9249 | 2 A/N | |
| 9250 | 837: (I) 2 420B REF01 | |
| 9251 | Print: N/A | |
| 9252 | Biller Inp ut: Screen 5 Section 4 | |
| 9253 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9254 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9255 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9256 | Storage: | |
| 9257 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9258 | Or by Care Unit | |
| 9259 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9260 | Field: PRO VIDER ID T YPE (#.06) | |
| 9261 | Code set: 0B, 1G, G2 , LU | |
| 9262 | 15 | |
| 9263 | Other Oper ating Prov ider Secon dary ID(3) | |
| 9264 | 10 A/N | |
| 9265 | 837: (I) 2 420B REF02 | |
| 9266 | Print: N/A | |
| 9267 | Biller Inp ut: Screen 5 Sectio n 4 | |
| 9268 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9269 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9270 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9271 | Storage: | |
| 9272 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9273 | Or by Care Unit | |
| 9274 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9275 | Field: PRO VIDER ID ( #.07) | |
| 9276 | ||
| 9277 | LREN - Loo p 2420A/C (Line Rend ering Prov ider Data) [SEQ 193 .3] | |
| 9278 | Maximum on e record p er Line | |
| 9279 | (OPTIONAL – Max len gth 194 by tes) | |
| 9280 | Piece | |
| 9281 | Descriptio n | |
| 9282 | Max Length Data Type | |
| 9283 | 837/Print Location | |
| 9284 | VistA Inpu t/Storage | |
| 9285 | FSC Proces sing Comme nts | |
| 9286 | 1 | |
| 9287 | RECORD ID = ‘LREN’ | |
| 9288 | 4 A | |
| 9289 | ||
| 9290 | ||
| 9291 | ||
| 9292 | 2 | |
| 9293 | Service Li ne Counter | |
| 9294 | 6 N | |
| 9295 | 837: 2400 LX01 | |
| 9296 | Print: N/A | |
| 9297 | Biller Inp ut: N/A | |
| 9298 | The system will keep track of the order of Revenue Codes and procedure s and keep the corre ct line le vel record s together . | |
| 9299 | Storage: N /A | |
| 9300 | ||
| 9301 | 3 | |
| 9302 | Rendering Provider Q ualifier | |
| 9303 | 2 A/N | |
| 9304 | 837: | |
| 9305 | (P)2420A N M101 | |
| 9306 | (I) 2420C NM101 | |
| 9307 | Print: N/A | |
| 9308 | Biller Inp ut: N/A | |
| 9309 | Storage: N /A | |
| 9310 | Note: Alwa ys 82 | |
| 9311 | ||
| 9312 | 4 | |
| 9313 | Rendering Provider L ast Name | |
| 9314 | 60 A | |
| 9315 | 837: | |
| 9316 | (P)2420A N M103 | |
| 9317 | (I) 2420C NM103 | |
| 9318 | Print: N/A | |
| 9319 | Biller Inp ut: | |
| 9320 | Screen 4/5 Section 4 | |
| 9321 | Storage: | |
| 9322 | File: BILL /CLAIMS (# 399) | |
| 9323 | Subfile: P ROCEDURES (#304) | |
| 9324 | Subfile: L INE PROVID ER (#60) | |
| 9325 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9326 | NM102 = 1 | |
| 9327 | 5 | |
| 9328 | Rendering Provider F irst Name | |
| 9329 | 35 A | |
| 9330 | 837: | |
| 9331 | (P)2420A N M104 | |
| 9332 | (I) 2420C NM104 | |
| 9333 | Print: N/A | |
| 9334 | Biller Inp ut: | |
| 9335 | Screen 4/5 Section 4 | |
| 9336 | Storage: | |
| 9337 | File: BILL /CLAIMS (# 399) | |
| 9338 | Subfile: P ROCEDURES (#304) | |
| 9339 | Subfile: L INE PROVID ER (#60) | |
| 9340 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9341 | ||
| 9342 | 6 | |
| 9343 | Rendering Provider M iddle | |
| 9344 | 1 A | |
| 9345 | 837: | |
| 9346 | (P)2420A N M105 | |
| 9347 | (I) 2420C NM105 | |
| 9348 | Print: N/A | |
| 9349 | Biller Inp ut: | |
| 9350 | Screen 4/5 Section 4 | |
| 9351 | Storage: | |
| 9352 | File: BILL /CLAIMS (# 399) | |
| 9353 | Subfile: P ROCEDURES (#304) | |
| 9354 | Subfile: L INE PROVID ER (#60) | |
| 9355 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9356 | ||
| 9357 | 7 | |
| 9358 | Rendering Provider N ame Suffix | |
| 9359 | 10 A | |
| 9360 | 837: | |
| 9361 | (P)2420A N M107 | |
| 9362 | (I) 2420C NM107 | |
| 9363 | Print: N/A | |
| 9364 | Biller Inp ut: | |
| 9365 | Screen 4/5 Section 4 | |
| 9366 | Storage: | |
| 9367 | File: BILL /CLAIMS (# 399) | |
| 9368 | Subfile: P ROCEDURES (#304) | |
| 9369 | Subfile: L INE PROVID ER (#60) | |
| 9370 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9371 | ||
| 9372 | 8 | |
| 9373 | Rendering provider P rimary ID Qualifier | |
| 9374 | 2 A | |
| 9375 | 837: | |
| 9376 | (P)2420A N M108 | |
| 9377 | (I) 2420C NM108 | |
| 9378 | Print: N/A | |
| 9379 | Biller Inp ut: N/A | |
| 9380 | Storage: N /A | |
| 9381 | Note: Alwa ys XX | |
| 9382 | ||
| 9383 | 9 | |
| 9384 | Rendering Provider P rimary ID | |
| 9385 | 10 N | |
| 9386 | 837: | |
| 9387 | (P)2420A N M109 | |
| 9388 | (I) 2420C NM109 | |
| 9389 | Print: CMS 1500 - 24 J | |
| 9390 | Biller Inp ut: N/A | |
| 9391 | The biller can add a provider to a claim but the p rovider’s NPI comes from the N ew Person file. | |
| 9392 | Storage: | |
| 9393 | File: NEW PERSON (#2 00) | |
| 9394 | Field: NPI (#41.99) | |
| 9395 | ||
| 9396 | 10 | |
| 9397 | Rendering Provider S econdary I D Qualifie r (1) | |
| 9398 | 2 A/N | |
| 9399 | 837: | |
| 9400 | (P)2420A R EF01 | |
| 9401 | (I) 2420C REF01 | |
| 9402 | Print: N/A | |
| 9403 | Biller Inp ut: Screen 5 Section 4 | |
| 9404 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9405 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9406 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9407 | Storage: | |
| 9408 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9409 | Or by Care Unit | |
| 9410 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9411 | Field: PRO VIDER ID T YPE (#.06) | |
| 9412 | Code set: 0B, 1G, G2 , LU | |
| 9413 | 11 | |
| 9414 | Rendering Provider S econdary I D(1) | |
| 9415 | 10 A/N | |
| 9416 | 837: | |
| 9417 | (P)2420A R EF02 | |
| 9418 | (I) 2420C REF02 | |
| 9419 | Print: | |
| 9420 | ||
| 9421 | Biller Inp ut: Screen 5 Sectio n 4 | |
| 9422 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9423 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9424 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9425 | Storage: | |
| 9426 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9427 | Or by Care Unit | |
| 9428 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9429 | Field: PRO VIDER ID ( #.07) | |
| 9430 | ||
| 9431 | 12 | |
| 9432 | Rendering Provider S econdary I D Qualifie r (2) | |
| 9433 | 2 A/N | |
| 9434 | 837: | |
| 9435 | (P)2420A R EF01 | |
| 9436 | (I) 2420C REF01 | |
| 9437 | Print: N/A | |
| 9438 | Biller Inp ut: Screen 5 Section 4 | |
| 9439 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9440 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9441 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9442 | Storage: | |
| 9443 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9444 | Or by Care Unit | |
| 9445 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9446 | Field: PRO VIDER ID T YPE (#.06) | |
| 9447 | Code set:0 B, 1G, G2, LU | |
| 9448 | 13 | |
| 9449 | Rendering Provider S econdary I D(2) | |
| 9450 | 10 A/N | |
| 9451 | 837: | |
| 9452 | (P)2420A R EF01 | |
| 9453 | (I) 2420C REF01 | |
| 9454 | Print: N/A | |
| 9455 | Biller Inp ut: Screen 5 Sectio n 4 | |
| 9456 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9457 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9458 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9459 | Storage: | |
| 9460 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9461 | Or by Care Unit | |
| 9462 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9463 | Field: PRO VIDER ID ( #.07) | |
| 9464 | ||
| 9465 | 14 | |
| 9466 | Rendering Provider S econdary I D Qualifie r (3) | |
| 9467 | 2 A/N | |
| 9468 | 837: | |
| 9469 | (P)2420A R EF01 | |
| 9470 | (I) 2420C REF01 | |
| 9471 | Print: N/A | |
| 9472 | Biller Inp ut: Screen 5 Section 4 | |
| 9473 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9474 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9475 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9476 | Storage: | |
| 9477 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9478 | Or by Care Unit | |
| 9479 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9480 | Field: PRO VIDER ID T YPE (#.06) | |
| 9481 | Code set: 0B, 1G, G2 , LU | |
| 9482 | 15 | |
| 9483 | Rendering Provider S econdary I D(3) | |
| 9484 | 10 A/N | |
| 9485 | 837: | |
| 9486 | (P)2420A R EF02 | |
| 9487 | (I) 2420C REF02 | |
| 9488 | Print: N/A | |
| 9489 | Biller Inp ut: Screen 5 Sectio n 4 | |
| 9490 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9491 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9492 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9493 | Storage: | |
| 9494 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9495 | Or by Care Unit | |
| 9496 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9497 | Field: PRO VIDER ID ( #.07) | |
| 9498 | ||
| 9499 | 16 | |
| 9500 | Rendering Provider T axonomy Qu alifier | |
| 9501 | 2 A | |
| 9502 | 837: (P)24 20A PRV01 | |
| 9503 | Print: N/A | |
| 9504 | Biller Inp ut: N/A | |
| 9505 | Storage: N /A | |
| 9506 | Note: Alwa ys PE | |
| 9507 | ||
| 9508 | 17 | |
| 9509 | Rendering Provider T axonomy Co de | |
| 9510 | 10 A | |
| 9511 | 837: (P)24 20A PRV03 | |
| 9512 | Print: N/A | |
| 9513 | Biller Inp ut: Screen 10 Sectio n 3 | |
| 9514 | The physic ian’s taxo nomy code is default ed from th e New Pers onPerson C lass file but may be overridde n by the b iller. | |
| 9515 | Storage: | |
| 9516 | File: BILL /CLAIMS (# 399) | |
| 9517 | Subfile: P ROVIDER (# 222) | |
| 9518 | Field: TAX ONOMY (#.1 5) | |
| 9519 | PRV02 = PX C | |
| 9520 | ||
| 9521 | LPUR - Loo p 2420B (L ine Purcha se Service Provider Data) [SE Q 193.6] | |
| 9522 | Maximum on e record p er Line | |
| 9523 | (OPTIONAL – Max len gth 42 byt es) | |
| 9524 | Piece | |
| 9525 | Descriptio n | |
| 9526 | Max Length Data Type | |
| 9527 | 837/VPE Lo cation | |
| 9528 | VistA Inpu t/Storage | |
| 9529 | FSC Proces sing Comme nts | |
| 9530 | 1 | |
| 9531 | RECORD ID = ‘LPUR’ | |
| 9532 | 4 A | |
| 9533 | ||
| 9534 | ||
| 9535 | ||
| 9536 | 2 | |
| 9537 | Service Li ne Counter | |
| 9538 | 6 N | |
| 9539 | 837: 2400 LX01 | |
| 9540 | Print: N/A | |
| 9541 | Biller Inp ut: N/A | |
| 9542 | The system will keep track of the order of Revenue Codes and procedure s and keep the corre ct line le vel record s together . | |
| 9543 | Storage: N /A | |
| 9544 | ||
| 9545 | 3 | |
| 9546 | Purchase S ervice Pro vider Qual ifier | |
| 9547 | 2 A | |
| 9548 | 837: (P)24 20B NM101 | |
| 9549 | Print: N/A | |
| 9550 | Biller Inp ut: N/A | |
| 9551 | Storage: N /A | |
| 9552 | Note: Alwa ys QB | |
| 9553 | Set NM102 = 1 | |
| 9554 | 4 | |
| 9555 | Purchase S ervice Pro vider Prim ary ID Qua lifier | |
| 9556 | 2 A | |
| 9557 | 837: (P)24 20B NM108 | |
| 9558 | Print: N/A | |
| 9559 | Biller Inp ut: N/A | |
| 9560 | Storage: N /A | |
| 9561 | Note: Alwa ys XX | |
| 9562 | ||
| 9563 | 5 | |
| 9564 | Purchase S ervice Pro vider Prim ary ID | |
| 9565 | 10 N | |
| 9566 | 837: (P)24 20B NM109 | |
| 9567 | Print: N/A | |
| 9568 | Biller Inp ut: | |
| 9569 | Fee: Scree n 10 Secti on 4 | |
| 9570 | Users may add an Out side Facil ity to a claim but the facili ty is defi ned in SYS TPROVNF of Provider ID Mainten ance. The NPI becom es the Pri mary ID. | |
| 9571 | Storage: | |
| 9572 | File: IB N ON/OTHER V A BILLING PROVIDER ( #355.93) | |
| 9573 | Field: NPI (#41.01) | |
| 9574 | ||
| 9575 | 6 | |
| 9576 | Purchase S ervice Pro vider Seco ndary ID Q ualifier ( 1) | |
| 9577 | 2 A/N | |
| 9578 | 837: (P)24 20B REF01 | |
| 9579 | Print: N/A | |
| 9580 | Biller Inp ut: | |
| 9581 | Fee: Scree n 10 Secti on 4 | |
| 9582 | Users may add an Out side Facil ity to a claim but the facili ty is defi ned in SYS TPROVNF of Provider ID Mainten ance. Sec ondary IDs can be th e provider ’s own ID or an ID a ssigned by a payer. | |
| 9583 | Storage: | |
| 9584 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9585 | Field: PRO VIDER ID T YPE (#.06) | |
| 9586 | Code set: 0B, 1G, G2 | |
| 9587 | 7 | |
| 9588 | Purchase S ervice Pro vider Seco ndary ID(1 ) | |
| 9589 | 10 A/N | |
| 9590 | 837: (P)RE F02 | |
| 9591 | Print: N/A | |
| 9592 | Biller Inp ut: | |
| 9593 | Fee: Scree n 10 Secti on 4 | |
| 9594 | Storage: | |
| 9595 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9596 | Field: PRO VIDER ID ( #.07) | |
| 9597 | ||
| 9598 | ||
| 9599 | LSUP - Loo p 2420D (L ine Superv ising Prov ider Data) [SEQ 194 ] | |
| 9600 | Maximum on e record p er Line | |
| 9601 | (OPTIONAL – Max len gth 180 by tes) | |
| 9602 | Piece | |
| 9603 | Descriptio n | |
| 9604 | Max Length Data Type | |
| 9605 | 837/Print Location | |
| 9606 | VistA Inpu t/Storage | |
| 9607 | FSC Proces sing Comme nts | |
| 9608 | 1 | |
| 9609 | RECORD ID = ‘LSUP’ | |
| 9610 | 4 A | |
| 9611 | ||
| 9612 | ||
| 9613 | ||
| 9614 | 2 | |
| 9615 | Service Li ne Counter | |
| 9616 | 6 N | |
| 9617 | 837: (P) 2 400 LX01 | |
| 9618 | Print: N/A | |
| 9619 | Biller Inp ut: N/A | |
| 9620 | The system will keep track of the order of Revenue Codes and procedure s and keep the corre ct line le vel record s together . | |
| 9621 | Storage: N /A | |
| 9622 | ||
| 9623 | 3 | |
| 9624 | Supervisin g Provider Qualifier | |
| 9625 | 2 A | |
| 9626 | 837: (P)24 20D NM101 | |
| 9627 | Print: N/A | |
| 9628 | Biller Inp ut: N/A | |
| 9629 | Storage: N /A | |
| 9630 | Note: Alwa ys DQ | |
| 9631 | ||
| 9632 | 4 | |
| 9633 | Supervisin g Provider Last Name | |
| 9634 | 60 A | |
| 9635 | 837: (P)24 20D NM103 | |
| 9636 | Print: N/A | |
| 9637 | Biller Inp ut: | |
| 9638 | Screen 4/5 Section 4 | |
| 9639 | Storage: | |
| 9640 | File: BILL /CLAIMS (# 399) | |
| 9641 | Subfile: P ROCEDURES (#304) | |
| 9642 | Subfile: L INE PROVID ER (#60) | |
| 9643 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9644 | NM102 = 1 | |
| 9645 | 5 | |
| 9646 | Supervisin g Provider First Nam e | |
| 9647 | 35 A | |
| 9648 | 837: (P)24 20D NM104 | |
| 9649 | Print: N/A | |
| 9650 | Biller Inp ut: | |
| 9651 | Screen 4/5 Section 4 | |
| 9652 | Storage: | |
| 9653 | File: BILL /CLAIMS (# 399) | |
| 9654 | Subfile: P ROCEDURES (#304) | |
| 9655 | Subfile: L INE PROVID ER (#60) | |
| 9656 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9657 | ||
| 9658 | 6 | |
| 9659 | Supervisin g Provider Middle | |
| 9660 | 1 A | |
| 9661 | 837: (P)24 20D NM105 | |
| 9662 | Print: N/A | |
| 9663 | Biller Inp ut: | |
| 9664 | Screen 4/5 Section 4 | |
| 9665 | Storage: | |
| 9666 | File: BILL /CLAIMS (# 399) | |
| 9667 | Subfile: P ROCEDURES (#304) | |
| 9668 | Subfile: L INE PROVID ER (#60) | |
| 9669 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9670 | ||
| 9671 | 7 | |
| 9672 | Supervisin g Provider Name Suff ix | |
| 9673 | 10 A | |
| 9674 | 837: (P)24 20D NM107 | |
| 9675 | Print: N/A | |
| 9676 | Biller Inp ut: | |
| 9677 | Screen 4/5 Section 4 | |
| 9678 | Storage: | |
| 9679 | File: BILL /CLAIMS (# 399) | |
| 9680 | Subfile: P ROCEDURES (#304) | |
| 9681 | Subfile: L INE PROVID ER (#60) | |
| 9682 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9683 | ||
| 9684 | 8 | |
| 9685 | Supervisin g Provider Primary I D Qualifie r | |
| 9686 | 2 A | |
| 9687 | 837: (P)24 20D NM108 | |
| 9688 | Print: N/A | |
| 9689 | Biller Inp ut: N/A | |
| 9690 | Storage: N /A | |
| 9691 | Note: Alwa ys XX | |
| 9692 | ||
| 9693 | ||
| 9694 | 9 | |
| 9695 | Supervisin g Provider Primary I D | |
| 9696 | 10 N | |
| 9697 | 837: (P)24 20D NM109 | |
| 9698 | Print: N/A | |
| 9699 | Biller Inp ut: N/A | |
| 9700 | The biller can add a provider to a claim but the p rovider’s NPI comes from the N ew Person file. | |
| 9701 | Storage: | |
| 9702 | File: NEW PERSON (#2 00) | |
| 9703 | Field: NPI (#41.99) | |
| 9704 | ||
| 9705 | 10 | |
| 9706 | Supervisin g Provider Secondary ID Qualif ier (1) | |
| 9707 | 2 A/N | |
| 9708 | 837: (P)24 20D REF01 | |
| 9709 | Print: N/A | |
| 9710 | Biller Inp ut: Screen 5 Section 4 | |
| 9711 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9712 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9713 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9714 | Storage: | |
| 9715 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9716 | Or by Care Unit | |
| 9717 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9718 | Field: PRO VIDER ID T YPE (#.06) | |
| 9719 | Code set: 0B, 1G, G2 , LU | |
| 9720 | 11 | |
| 9721 | Supervisin g Provider Secondary ID(1) | |
| 9722 | 10 A/N | |
| 9723 | 837: (P)24 20D REF02 | |
| 9724 | Print: N/A | |
| 9725 | Biller Inp ut: Screen 5 Sectio n 4 | |
| 9726 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9727 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9728 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9729 | Storage: | |
| 9730 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9731 | Or by Care Unit | |
| 9732 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9733 | Field: PRO VIDER ID ( #.07) | |
| 9734 | ||
| 9735 | 12 | |
| 9736 | Supervisin g Provider Secondary ID Qualif ier (2) | |
| 9737 | 2 A/N | |
| 9738 | 837: (P)24 20D REF01 | |
| 9739 | Print: N/A | |
| 9740 | Biller Inp ut: Screen 5 Section 4 | |
| 9741 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9742 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9743 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9744 | Storage: | |
| 9745 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9746 | Or by Care Unit | |
| 9747 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9748 | Field: PRO VIDER ID T YPE (#.06) | |
| 9749 | Code set: 0B, 1G, G2 , LU | |
| 9750 | 13 | |
| 9751 | Supervisin g Provider Secondary ID(2) | |
| 9752 | 10 A/N | |
| 9753 | 837: (P)24 20D REF02 | |
| 9754 | Print: N/A | |
| 9755 | Biller Inp ut: Screen 5 Sectio n 4 | |
| 9756 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9757 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9758 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9759 | Storage: | |
| 9760 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9761 | Or by Care Unit | |
| 9762 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9763 | Field: PRO VIDER ID ( #.07) | |
| 9764 | ||
| 9765 | 14 | |
| 9766 | Supervisin g Provider Secondary ID Qualif ier (3) | |
| 9767 | 2 A/N | |
| 9768 | 837: (P)24 20D REF01 | |
| 9769 | Print: N/A | |
| 9770 | Biller Inp ut: Screen 5 Section 4 | |
| 9771 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9772 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9773 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9774 | Storage: | |
| 9775 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9776 | Or by Care Unit | |
| 9777 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9778 | Field: PRO VIDER ID T YPE (#.06) | |
| 9779 | Code set: 0B, 1G, G2 , LU | |
| 9780 | 15 | |
| 9781 | Supervisin g Provider Secondary ID(3) | |
| 9782 | 10 A/N | |
| 9783 | 837: (P)24 20D REF02 | |
| 9784 | Print: N/A | |
| 9785 | Biller Inp ut: Screen 5 Sectio n 4 | |
| 9786 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9787 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9788 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9789 | Storage: | |
| 9790 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9791 | Or by Care Unit | |
| 9792 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9793 | Field: PRO VIDER ID ( #.07) | |
| 9794 | ||
| 9795 | ||
| 9796 | ||
| 9797 | LREF - Loo p 2420F/D (Line Refe rring Prov ider Data) [SEQ 194 .3] | |
| 9798 | Max two re cord per L ine | |
| 9799 | (OPTIONAL – Max leng th 180 byt es) | |
| 9800 | Piece | |
| 9801 | Descriptio n | |
| 9802 | Max Length Data Type | |
| 9803 | 837/Print Location | |
| 9804 | VistA Inpu t/Storage | |
| 9805 | FSC Proces sing Comme nts | |
| 9806 | 1 | |
| 9807 | RECORD ID = ‘LREF’ | |
| 9808 | 4 A | |
| 9809 | ||
| 9810 | ||
| 9811 | ||
| 9812 | 2 | |
| 9813 | Service Li ne Counter | |
| 9814 | 6 N | |
| 9815 | 837: 2400 LX01 | |
| 9816 | Print: N/A | |
| 9817 | Biller Inp ut: N/A | |
| 9818 | The system will keep track of the order of Revenue Codes and procedure s and keep the corre ct line le vel record s together . | |
| 9819 | Storage: N /A | |
| 9820 | ||
| 9821 | 3 | |
| 9822 | Referring Provider Q ualifier | |
| 9823 | 2 A/N | |
| 9824 | 837: | |
| 9825 | (P)2420F N M101 | |
| 9826 | (I)2420D N M101 | |
| 9827 | Print: N/A | |
| 9828 | Biller Inp ut: N/A | |
| 9829 | Storage: N /A | |
| 9830 | Note: Alwa ys DN | |
| 9831 | ||
| 9832 | 4 | |
| 9833 | Referring Provider L ast Name | |
| 9834 | 60 A | |
| 9835 | 837: | |
| 9836 | (P)2420F N M103 | |
| 9837 | (I) 2420D NM103 | |
| 9838 | Print: N/A | |
| 9839 | Biller Inp ut: | |
| 9840 | Screen 4/5 Section 4 | |
| 9841 | Storage: | |
| 9842 | File: BILL /CLAIMS (# 399) | |
| 9843 | Subfile: P ROCEDURES (#304) | |
| 9844 | Subfile: L INE PROVID ER (#60) | |
| 9845 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9846 | NM102 = 1 | |
| 9847 | 5 | |
| 9848 | Referring Provider F irst Name | |
| 9849 | 35 A | |
| 9850 | 837: | |
| 9851 | (P)2420F N M104 | |
| 9852 | (I) 2420D NM104 | |
| 9853 | Print: N/A | |
| 9854 | Biller Inp ut: | |
| 9855 | Screen 4/5 Section 4 | |
| 9856 | Storage: | |
| 9857 | File: BILL /CLAIMS (# 399) | |
| 9858 | Subfile: P ROCEDURES (#304) | |
| 9859 | Subfile: L INE PROVID ER (#60) | |
| 9860 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9861 | ||
| 9862 | 6 | |
| 9863 | Referring Provider M iddle | |
| 9864 | 1 A | |
| 9865 | 837: | |
| 9866 | (P)2420F N M105 | |
| 9867 | (I) 2420D NM105 | |
| 9868 | Print: N/A | |
| 9869 | Biller Inp ut: | |
| 9870 | Screen 4/5 Section 4 | |
| 9871 | Storage: | |
| 9872 | File: BILL /CLAIMS (# 399) | |
| 9873 | Subfile: P ROCEDURES (#304) | |
| 9874 | Subfile: L INE PROVID ER (#60) | |
| 9875 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9876 | ||
| 9877 | 7 | |
| 9878 | Referring Provider N ame Suffix | |
| 9879 | 10 A | |
| 9880 | 837: | |
| 9881 | (P)2420F N M107 | |
| 9882 | (I) 2420D NM107 | |
| 9883 | Print: N/A | |
| 9884 | Biller Inp ut: | |
| 9885 | Screen 4/5 Section 4 | |
| 9886 | Storage: | |
| 9887 | File: BILL /CLAIMS (# 399) | |
| 9888 | Subfile: P ROCEDURES (#304) | |
| 9889 | Subfile: L INE PROVID ER (#60) | |
| 9890 | Field: LIN E PERFORME D BY (#.02 ) | |
| 9891 | ||
| 9892 | 8 | |
| 9893 | Referring Provider P rimary ID Qualifier | |
| 9894 | 2 A | |
| 9895 | 837: | |
| 9896 | (P)2420F N M108 | |
| 9897 | (I) 2420D NM108 | |
| 9898 | Biller Inp ut: N/A | |
| 9899 | Storage: N /A | |
| 9900 | Note: Alwa ys XX | |
| 9901 | ||
| 9902 | 9 | |
| 9903 | Referring Provider P rimary ID | |
| 9904 | 10 N | |
| 9905 | 837: | |
| 9906 | (P)2420F N M109 | |
| 9907 | (I) 2420D NM109 | |
| 9908 | Biller Inp ut: N/A | |
| 9909 | The biller can add a provider to a claim but the p rovider’s NPI comes from the N ew Person file. | |
| 9910 | Storage: | |
| 9911 | File: NEW PERSON (#2 00) | |
| 9912 | Field: NPI (#41.99) | |
| 9913 | ||
| 9914 | 10 | |
| 9915 | Referring Provider S econdary I D Qualifie r (1) | |
| 9916 | 2 A/N | |
| 9917 | 837: | |
| 9918 | (P)2420F R EF01 | |
| 9919 | (I) 2420D REF01 | |
| 9920 | Print: N/A | |
| 9921 | Biller Inp ut: Screen 5 Section 4 | |
| 9922 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9923 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9924 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9925 | Storage: | |
| 9926 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9927 | Or by Care Unit | |
| 9928 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9929 | Field: PRO VIDER ID T YPE (#.06) | |
| 9930 | Code set: 0B, 1G, G2 | |
| 9931 | 11 | |
| 9932 | Referring Provider S econdary I D(1) | |
| 9933 | 10 A/N | |
| 9934 | 837: | |
| 9935 | (P)2420F R EF02 | |
| 9936 | (I) 2420D REF02 | |
| 9937 | Print: N/A | |
| 9938 | Biller Inp ut: Screen 5 Sectio n 4 | |
| 9939 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9940 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9941 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9942 | Storage: | |
| 9943 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9944 | Or by Care Unit | |
| 9945 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9946 | Field: PRO VIDER ID ( #.07) | |
| 9947 | ||
| 9948 | 12 | |
| 9949 | Referring Provider S econdary I D Qualifie r (2) | |
| 9950 | 2 A/N | |
| 9951 | 837: (P)24 20F REF01 | |
| 9952 | (I) 2420D REF01 | |
| 9953 | Biller Inp ut: Screen 5 Section 4 | |
| 9954 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9955 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9956 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9957 | Storage: | |
| 9958 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9959 | Or by Care Unit | |
| 9960 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9961 | Field: PRO VIDER ID T YPE (#.06) | |
| 9962 | Code set: 0B, 1G, G2 | |
| 9963 | 13 | |
| 9964 | Referring Provider S econdary I D(2) | |
| 9965 | 10 A/N | |
| 9966 | 837: | |
| 9967 | (P)2420F R EF02 | |
| 9968 | (I) 2420D REF02 | |
| 9969 | Print: N/A | |
| 9970 | Biller Inp ut: Screen 5 Sectio n 4 | |
| 9971 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9972 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9973 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9974 | Storage: | |
| 9975 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9976 | Or by Care Unit | |
| 9977 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9978 | Field: PRO VIDER ID ( #.07) | |
| 9979 | ||
| 9980 | 14 | |
| 9981 | Referring Provider S econdary I D Qualifie r (3) | |
| 9982 | 2 A/N | |
| 9983 | 837: | |
| 9984 | (P)2420F R EF01 | |
| 9985 | (I) 2420D REF01 | |
| 9986 | Print: N/A | |
| 9987 | Biller Inp ut: Screen 5 Section 4 | |
| 9988 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 9989 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 9990 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 9991 | Storage: | |
| 9992 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 9993 | Or by Care Unit | |
| 9994 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 9995 | Field: PRO VIDER ID T YPE (#.06) | |
| 9996 | Code set: 0B, 1G, G2 | |
| 9997 | 15 | |
| 9998 | Referring Provider S econdary I D(3) | |
| 9999 | 10 A/N | |
| 10000 | 837: | |
| 10001 | (P)2420F R EF02 | |
| 10002 | (I) 2420D REF02 | |
| 10003 | Print: N/A | |
| 10004 | Biller Inp ut: Screen 5 Sectio n 4 | |
| 10005 | Users may add a one- time Secon dary ID wh en they ad d the prov ider to a claim. | |
| 10006 | Provider S econdary I Ds and Qua lifiers ar e maintain ed in Prov ider ID Ma intenance. Providers may have their own IDs or the y may have IDs assig ned to the m by a pay er. | |
| 10007 | The billin g software will auto matically pull a pro vider’s ID s from Pro vider ID M aintenance . | |
| 10008 | Storage: | |
| 10009 | File: IB B ILLING PRA CTITIONER ID (#355.9 ) | |
| 10010 | Or by Care Unit | |
| 10011 | File: IB I NSURANCE C O LEVEL BI LLING PROV IDER ID (# 355.91) | |
| 10012 | Field: PRO VIDER ID ( #.07) | |
| 10013 | ||
| 10014 | ||
| 10015 | ||
| 10016 | Section 6 – Other In surance Li ne Level D ata | |
| 10017 | LCOB - Loo p 2430 (CO B Service Line Adjud ication Da ta) [SEQ 1 95] | |
| 10018 | Maximum on e record p er Line #/ payer id o n INS/PRF/ RX1 record | |
| 10019 | (OPTIONAL – Max leng th 230 byt es) | |
| 10020 | Piece | |
| 10021 | Descriptio n | |
| 10022 | Max Length Data Type | |
| 10023 | 837/Print Location | |
| 10024 | VistA Inpu t/Storage | |
| 10025 | FSC Proces sing Comme nts | |
| 10026 | 1 | |
| 10027 | RECORD ID = ‘LCOB’ | |
| 10028 | 4 A | |
| 10029 | ||
| 10030 | ||
| 10031 | ||
| 10032 | 2 | |
| 10033 | Service Li ne Counter | |
| 10034 | ||
| 10035 | 6 N | |
| 10036 | 837: 2400 LX01 | |
| 10037 | Print: N/A | |
| 10038 | Biller Inp ut: N/A | |
| 10039 | The system will keep track of the order of Revenue Codes and procedure s and keep the corre ct line le vel record s together . | |
| 10040 | Storage: N /A | |
| 10041 | ||
| 10042 | 3 | |
| 10043 | Payer ID | |
| 10044 | 20 A/N | |
| 10045 | 837: 2430 SVD01 | |
| 10046 | Print: N/A | |
| 10047 | Biller Inp ut: N/A | |
| 10048 | Storage: | |
| 10049 | File: INSU RANCE COMP ANY (#36) | |
| 10050 | Field: EDI ID NUMBER – PROF (# 3.02) | |
| 10051 | Field: EDI ID NUMBER – INST (# 3.04) | |
| 10052 | Field: HPI D (# TBD) | |
| 10053 | ||
| 10054 | 4 | |
| 10055 | Service Li ne Paid Am t | |
| 10056 | 15 N | |
| 10057 | 2 Decimals | |
| 10058 | 837: 2430 SVD02 | |
| 10059 | Print: N/A | |
| 10060 | Biller Inp ut: N/A | |
| 10061 | Storage: | |
| 10062 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10063 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10064 | Field: AMO UNT PAID ( #.03) | |
| 10065 | ||
| 10066 | 5 | |
| 10067 | Procedure Code | |
| 10068 | 20 A/N | |
| 10069 | 837: 2430 SVD03 – 2 | |
| 10070 | Print: N/A | |
| 10071 | Biller Inp ut: N/A | |
| 10072 | Storage: | |
| 10073 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10074 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10075 | Field: PRO CEDURE (#. 04) | |
| 10076 | Set SVD03 – 1 = HC | |
| 10077 | 6 | |
| 10078 | Service Li ne Revenue Code | |
| 10079 | 10 A/N | |
| 10080 | 837: 2430 SVD04 | |
| 10081 | Print: N/A | |
| 10082 | Biller Inp ut: N/A | |
| 10083 | Storage: | |
| 10084 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10085 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10086 | Field: REV ENUE CODE (#.1) | |
| 10087 | Element re moved in 5 010 final rule and r e-instated in the er rata. | |
| 10088 | 7 | |
| 10089 | Procedure Modifier ( 1) | |
| 10090 | 2 A/N | |
| 10091 | 837: 2430 SVD03 - 3 | |
| 10092 | Print: N/A | |
| 10093 | Biller Inp ut: N/A | |
| 10094 | Storage: | |
| 10095 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10096 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10097 | Subfile: P AID MODIFI ERS (#2) | |
| 10098 | Field: PAI D MODIFIER S (#.01) | |
| 10099 | ||
| 10100 | 8 | |
| 10101 | Procedure Modifier ( 2) | |
| 10102 | 2 A/N | |
| 10103 | 837: 2430 SVD03 – 4 | |
| 10104 | Print: N/A | |
| 10105 | Biller Inp ut: N/A | |
| 10106 | Storage: | |
| 10107 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10108 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10109 | Subfile: P AID MODIFI ERS (#2) | |
| 10110 | Field: PAI D MODIFIER S (#.01) | |
| 10111 | ||
| 10112 | 9 | |
| 10113 | Procedure Modifier ( 3) | |
| 10114 | 2 A/N | |
| 10115 | 837: 2430 SVD03 – 5 | |
| 10116 | Print: N/A | |
| 10117 | Biller Inp ut: N/A | |
| 10118 | Storage: | |
| 10119 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10120 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10121 | Subfile: P AID MODIFI ERS (#2) | |
| 10122 | Field: PAI D MODIFIER S (#.01) | |
| 10123 | ||
| 10124 | 10 | |
| 10125 | Procedure Modifier ( 4) | |
| 10126 | 2 A/N | |
| 10127 | 837: 2430 SVD03 – 6 | |
| 10128 | Print: N/A | |
| 10129 | Biller Inp ut: N/A | |
| 10130 | Storage: | |
| 10131 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10132 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10133 | Subfile: P AID MODIFI ERS (#2) | |
| 10134 | Field: PAI D MODIFIER S (#.01) | |
| 10135 | ||
| 10136 | 11 | |
| 10137 | Procedure Code Descr iption | |
| 10138 | 80 A/N | |
| 10139 | 837: 2430 SVD03 – 7 | |
| 10140 | Print: N/A | |
| 10141 | Biller Inp ut: N/A | |
| 10142 | Storage: | |
| 10143 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10144 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10145 | Field: DES CRIPTION ( #.09) | |
| 10146 | ||
| 10147 | 12 | |
| 10148 | Paid Servi ce Unit Co unt | |
| 10149 | 15 N | |
| 10150 | 837: (P) 2 430 SVD05 | |
| 10151 | Print: N/A | |
| 10152 | Biller Inp ut: N/A | |
| 10153 | Storage: | |
| 10154 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10155 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10156 | Field: PAI D UNITS OF SERVICE ( #.11) | |
| 10157 | ||
| 10158 | 13 | |
| 10159 | Bundled Li ne Number | |
| 10160 | 6 N | |
| 10161 | 837: (P) 2 430 SVD06 | |
| 10162 | Print: N/A | |
| 10163 | Biller Inp ut: N/A | |
| 10164 | Storage: | |
| 10165 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10166 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10167 | Field: REF ERENCED LI NE # (#.12 ) | |
| 10168 | ||
| 10169 | 14 | |
| 10170 | Adjudicati on or Paym ent DT | |
| 10171 | 8 N CCYYMM DD | |
| 10172 | 837: (P) 2 430 DTP03 | |
| 10173 | Print: N/A | |
| 10174 | Biller Inp ut: N/A | |
| 10175 | Storage: | |
| 10176 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10177 | Field: EOB PAID DATE (#.06) | |
| 10178 | ||
| 10179 | 15 | |
| 10180 | Product or Service I D Qualifie r | |
| 10181 | 2 A | |
| 10182 | 837: 2430 SVD03 | |
| 10183 | Print: N/A | |
| 10184 | Biller Inp ut: N/A | |
| 10185 | Storage: N /A | |
| 10186 | ||
| 10187 | 16 | |
| 10188 | Remaining Liability Qualifier | |
| 10189 | 3 A | |
| 10190 | 837: 2430 AMT01 | |
| 10191 | Print: N/A | |
| 10192 | Biller Inp ut: N/A | |
| 10193 | Storage: N /A | |
| 10194 | Note: Alwa ys EAF | |
| 10195 | ||
| 10196 | 17 | |
| 10197 | Remaining Liability | |
| 10198 | 15 N | |
| 10199 | 2 Decimals | |
| 10200 | 837: 2430 AMT02 | |
| 10201 | Print: N/A | |
| 10202 | Biller Inp ut: N/A | |
| 10203 | Storage: | |
| 10204 | File: EXPL ANATION OF BENEIFITS (#361.1) | |
| 10205 | Field: PAT IENT RESPO NSIBILITY AMT (#1.02 ) | |
| 10206 | ||
| 10207 | 18 | |
| 10208 | Payer Resp onsibility Sequence # Code | |
| 10209 | 1 A | |
| 10210 | 837: N/A | |
| 10211 | Print: N/A | |
| 10212 | Biller Inp ut: Screen 3 Section 1 | |
| 10213 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers | |
| 10214 | Storage: | |
| 10215 | File: BILL /CLAIMS (# 399) | |
| 10216 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 10217 | Primary (P ), Seconda ry (S) ,Te rtiary (T) Must matc h value in OI1 piece 2 for ins urance. | |
| 10218 | ||
| 10219 | ||
| 10220 | LCAS - Loo p 2430 (CO B Line Lev el Adjustm ents) [SEQ 200] | |
| 10221 | One or mor e records per LCOB r ecord | |
| 10222 | (OPTIONAL – Max leng th 190 byt es) | |
| 10223 | Piece | |
| 10224 | Descriptio n | |
| 10225 | Max Length | |
| 10226 | Data Type | |
| 10227 | 837/Print Location | |
| 10228 | VistA Inpu t/Storage | |
| 10229 | FSC Proces sing Comme nts | |
| 10230 | 1 | |
| 10231 | RECORD ID = ‘LCAS’ | |
| 10232 | 4 A | |
| 10233 | ||
| 10234 | ||
| 10235 | ||
| 10236 | 2 | |
| 10237 | Service Li ne Counter | |
| 10238 | 6 N | |
| 10239 | 837: 2400 LX01 | |
| 10240 | Print: N/A | |
| 10241 | Biller Inp ut: N/A | |
| 10242 | The system will keep track of the order of Revenue Codes and procedure s and keep the corre ct line le vel record s together . | |
| 10243 | Storage: N /A | |
| 10244 | ||
| 10245 | 3 | |
| 10246 | Claim Adju stment Gro up Code | |
| 10247 | 2 A | |
| 10248 | 837: 2430 CAS01 | |
| 10249 | Print: N/A | |
| 10250 | Biller Inp ut: N/A | |
| 10251 | Storage: | |
| 10252 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10253 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10254 | Subfile: A DJUSTMENTS (#1) | |
| 10255 | Field: GRO UP CODE (# .01) | |
| 10256 | LQ is only valid for claims wi th CI5 pie ce 3 (dest ination pa yer ID) of IPRNT or PPRNT. | |
| 10257 | 4 | |
| 10258 | Adjustment Reason Co de (1) | |
| 10259 | 5 A/N | |
| 10260 | 837: 2430 CAS02 | |
| 10261 | Print: N/A | |
| 10262 | Biller Inp ut: N/A | |
| 10263 | Storage: | |
| 10264 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10265 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10266 | Subfile: A DJUSTMENTS (#1) | |
| 10267 | Subfile: R EASONS (#1 ) | |
| 10268 | Field: REA SON CODE ( #.01) | |
| 10269 | AAA is onl y valid fo r claims w ith CI5 pi ece 3 (des tination p ayer ID) o f IPRNT or PPRNT. | |
| 10270 | 5 | |
| 10271 | Adjustment Amt (1) | |
| 10272 | 15 N | |
| 10273 | 2 Decimals | |
| 10274 | 837: 2430 CAS03 | |
| 10275 | Print: N/A | |
| 10276 | Biller Inp ut: N/A | |
| 10277 | Storage: | |
| 10278 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10279 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10280 | Subfile: A DJUSTMENTS (#1) | |
| 10281 | Subfile: R EASONS (#1 ) | |
| 10282 | Field: AMO UNT (#.02) | |
| 10283 | Zero is va lid if LCA S piece 3 is LQ. | |
| 10284 | 6 | |
| 10285 | Adjustment Quantity (1) | |
| 10286 | 6 N | |
| 10287 | 837: 2430 CAS04 | |
| 10288 | Print: N/A | |
| 10289 | Biller Inp ut: N/A | |
| 10290 | Storage: | |
| 10291 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10292 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10293 | Subfile: A DJUSTMENTS (#1) | |
| 10294 | Subfile: R EASONS (#1 ) | |
| 10295 | Field: QUA NTITY (#.0 3) | |
| 10296 | Zero is va lid if LCA S piece 3 is LQ. | |
| 10297 | 7 | |
| 10298 | Adjustment Reason Co de (2) | |
| 10299 | 5 A/N | |
| 10300 | 837: 2430 CAS05 | |
| 10301 | Print: N/A | |
| 10302 | Biller Inp ut: N/A | |
| 10303 | Storage: | |
| 10304 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10305 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10306 | Subfile: A DJUSTMENTS (#1) | |
| 10307 | Subfile: R EASONS (#1 ) | |
| 10308 | Field: REA SON CODE ( #.01) | |
| 10309 | AAA is onl y valid fo r claims w ith CI5 pi ece 3 (des tination p ayer ID) o f IPRNT or PPRNT. | |
| 10310 | 8 | |
| 10311 | Adjustment Amt (2) | |
| 10312 | 15 N | |
| 10313 | 2 Decimals | |
| 10314 | 837: 2430 CAS06 | |
| 10315 | Print: N/A | |
| 10316 | Biller Inp ut: N/A | |
| 10317 | Storage: | |
| 10318 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10319 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10320 | Subfile: A DJUSTMENTS (#1) | |
| 10321 | Subfile: R EASONS (#1 ) | |
| 10322 | Field: AMO UNT (#.02) | |
| 10323 | Zero is va lid if LCA S piece 3 is LQ | |
| 10324 | 9 | |
| 10325 | Adjustment Quantity (2) | |
| 10326 | 6 N | |
| 10327 | 837: 2430 CAS07 | |
| 10328 | Print: N/A | |
| 10329 | Biller Inp ut: N/A | |
| 10330 | Storage: | |
| 10331 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10332 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10333 | Subfile: A DJUSTMENTS (#1) | |
| 10334 | Subfile: R EASONS (#1 ) | |
| 10335 | Field: QUA NTITY (#.0 3) | |
| 10336 | Zero is va lid if LCA S piece 3 is LQ | |
| 10337 | 10 | |
| 10338 | Adjustment Reason Co de (3) | |
| 10339 | 5 A/N | |
| 10340 | 837: 2430 CAS08 | |
| 10341 | Print: N/A | |
| 10342 | Biller Inp ut: N/A | |
| 10343 | Storage: | |
| 10344 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10345 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10346 | Subfile: A DJUSTMENTS (#1) | |
| 10347 | Subfile: R EASONS (#1 ) | |
| 10348 | Field: REA SON CODE ( #.01) | |
| 10349 | AAA is onl y valid fo r claims w ith CI5 pi ece 3 (des tination p ayer ID) o f IPRNT or PPRNT. | |
| 10350 | 11 | |
| 10351 | Adjustment Amt (3) | |
| 10352 | 15 N | |
| 10353 | 2 Decimals | |
| 10354 | 837: 2430 CAS09 | |
| 10355 | Print: N/A | |
| 10356 | Biller Inp ut: N/A | |
| 10357 | Storage: | |
| 10358 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10359 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10360 | Subfile: A DJUSTMENTS (#1) | |
| 10361 | Subfile: R EASONS (#1 ) | |
| 10362 | Field: AMO UNT (#.02) | |
| 10363 | Zero is va lid if LCA S piece 3 is LQ | |
| 10364 | 12 | |
| 10365 | Adjustment Quantity (3) | |
| 10366 | 6 N | |
| 10367 | 837: 2430 CAS10 | |
| 10368 | Print: N/A | |
| 10369 | Biller Inp ut: N/A | |
| 10370 | Storage: | |
| 10371 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10372 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10373 | Subfile: A DJUSTMENTS (#1) | |
| 10374 | Subfile: R EASONS (#1 ) | |
| 10375 | Field: QUA NTITY (#.0 3) | |
| 10376 | Zero is va lid if LCA S piece 3 is LQ | |
| 10377 | 13 | |
| 10378 | Adjustment Reason Co de (4) | |
| 10379 | 5 A/N | |
| 10380 | 837: 2430 CAS11 | |
| 10381 | Print: N/A | |
| 10382 | Biller Inp ut: N/A | |
| 10383 | Storage: | |
| 10384 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10385 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10386 | Subfile: A DJUSTMENTS (#1) | |
| 10387 | Subfile: R EASONS (#1 ) | |
| 10388 | Field: REA SON CODE ( #.01) | |
| 10389 | AAA is onl y valid fo r claims w ith CI5 pi ece 3 (des tination p ayer ID) o f IPRNT or PPRNT. | |
| 10390 | 14 | |
| 10391 | Adjustment Amt (4) | |
| 10392 | 15 N | |
| 10393 | 2 Decimals | |
| 10394 | 837: 2430 CAS12 | |
| 10395 | Print: N/A | |
| 10396 | Biller Inp ut: N/A | |
| 10397 | Storage: | |
| 10398 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10399 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10400 | Subfile: A DJUSTMENTS (#1) | |
| 10401 | Subfile: R EASONS (#1 ) | |
| 10402 | Field: AMO UNT (#.02) | |
| 10403 | Zero is va lid if LCA S piece 3 is LQ | |
| 10404 | 15 | |
| 10405 | Adjustment Quantity( 4) | |
| 10406 | 6 N | |
| 10407 | 837: 2430 CAS13 | |
| 10408 | Print: N/A | |
| 10409 | Biller Inp ut: N/A | |
| 10410 | Storage: | |
| 10411 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10412 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10413 | Subfile: A DJUSTMENTS (#1) | |
| 10414 | Subfile: R EASONS (#1 ) | |
| 10415 | Field: QUA NTITY (#.0 3) | |
| 10416 | Zero is va lid if LCA S piece 3 is LQ | |
| 10417 | 16 | |
| 10418 | Adjustment Reason Co de (5) | |
| 10419 | 5 A/N | |
| 10420 | 837: 2430 CAS14 | |
| 10421 | Print: N/A | |
| 10422 | Biller Inp ut: N/A | |
| 10423 | Storage: | |
| 10424 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10425 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10426 | Subfile: A DJUSTMENTS (#1) | |
| 10427 | Subfile: R EASONS (#1 ) | |
| 10428 | Field: REA SON CODE ( #.01) | |
| 10429 | AAA is onl y valid fo r claims w ith CI5 pi ece 3 (des tination p ayer ID) o f IPRNT or PPRNT. | |
| 10430 | 17 | |
| 10431 | Adjustment Amt (5) | |
| 10432 | 15 N | |
| 10433 | 2 Decimals | |
| 10434 | 837: 2430 CAS15 | |
| 10435 | Print: N/A | |
| 10436 | Biller Inp ut: N/A | |
| 10437 | Storage: | |
| 10438 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10439 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10440 | Subfile: A DJUSTMENTS (#1) | |
| 10441 | Subfile: R EASONS (#1 ) | |
| 10442 | Field: AMO UNT (#.02) | |
| 10443 | Zero is va lid if LCA S piece 3 is LQ | |
| 10444 | 18 | |
| 10445 | Adjustment Quantity (5) | |
| 10446 | 6 N | |
| 10447 | 837: 2430 CAS16 | |
| 10448 | Print: N/A | |
| 10449 | Biller Inp ut: N/A | |
| 10450 | Storage: | |
| 10451 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10452 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10453 | Subfile: A DJUSTMENTS (#1) | |
| 10454 | Subfile: R EASONS (#1 ) | |
| 10455 | Field: QUA NTITY (#.0 3) | |
| 10456 | Zero is va lid if LCA S piece 3 is LQ | |
| 10457 | 19 | |
| 10458 | Adjustment Reason Co de (6) | |
| 10459 | 5 A/N | |
| 10460 | 837: 2430 CAS17 | |
| 10461 | Print: N/A | |
| 10462 | Biller Inp ut: N/A | |
| 10463 | Storage: | |
| 10464 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10465 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10466 | Subfile: A DJUSTMENTS (#1) | |
| 10467 | Subfile: R EASONS (#1 ) | |
| 10468 | Field: REA SON CODE ( #.01) | |
| 10469 | AAA is onl y valid fo r claims w ith CI5 pi ece 3 (des tination p ayer ID) o f IPRNT or PPRNT. | |
| 10470 | 20 | |
| 10471 | Adjustment Amt (6) | |
| 10472 | 15 N | |
| 10473 | 2 Decimals | |
| 10474 | 837: 2430 CAS18 | |
| 10475 | Print: N/A | |
| 10476 | Biller Inp ut: N/A | |
| 10477 | Storage: | |
| 10478 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10479 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10480 | Subfile: A DJUSTMENTS (#1) | |
| 10481 | Subfile: R EASONS (#1 ) | |
| 10482 | Field: AMO UNT (#.02) | |
| 10483 | Zero is va lid if LCA S piece 3 is LQ | |
| 10484 | 21 | |
| 10485 | Adjustment Quantity (6) | |
| 10486 | 6 N | |
| 10487 | 837: 2430 CAS19 | |
| 10488 | Print: N/A | |
| 10489 | Biller Inp ut: N/A | |
| 10490 | Storage: | |
| 10491 | File: EXPL ANATION OF BENEFITS (#361.1) | |
| 10492 | Subfile: 8 35 LINE LE VEL ADJUST MENTS (#15 ) | |
| 10493 | Subfile: A DJUSTMENTS (#1) | |
| 10494 | Subfile: R EASONS (#1 ) | |
| 10495 | Field: QUA NTITY (#.0 3) | |
| 10496 | Zero is va lid if LCA S piece 3 is | |
| 10497 | LQ | |
| 10498 | 22 | |
| 10499 | Payer Resp onsibility Sequence # Code | |
| 10500 | 1 A | |
| 10501 | 837: N/A | |
| 10502 | Print: N/A | |
| 10503 | Biller Inp ut: Screen 3 Section 1 | |
| 10504 | Note: A bi ller can i nitially d esignate a claim as P/T/S but depending on the num ber of pay ers on a c laim, the system wil l automati cally keep track of the curren t Payer se quence and which pay er(s) is t he destina tion payer or the Ot her payers . | |
| 10505 | Storage: | |
| 10506 | File: BILL /CLAIMS (# 399) | |
| 10507 | Field: CUR RENT BILL PAYER SEQU ENCE (#.21 ) | |
| 10508 | Primary (P ), Seconda ry (S),Ter tiary (T) Must match value in OI1 piece 2 for insu rance. | |
| 10509 | ||
| 10510 | Appendix B – FSC Map ping Rules | |
| 10511 | TPA Cleari nghouse ID | |
| 10512 | Program Na me: TPA C learinghou seID.exe | |
| 10513 | Overview | |
| 10514 | This prepr ocessor de fines the claim offi ce IDs whi ch may be used with the second ary cleari nghouse ID s. If a cl earinghous e ID - def ined on th e Edit Cle aringhouse ID page - is submit ted on a c laim, the claim offi ce ID valu e must mat ch one of the values in the ta ble below. | |
| 10515 | If a valid combinati on of clai m office I D and clea ringhouse ID is not found, the clearingh ouse ID an d claim of fice ID va lues are r emoved fro m the clai m and it i s forwarde d to the H CCH with a destinati on payer I D (CI5 -3 /2010BB NM 109) of nu ll. | |
| 10516 | Business C ase | |
| 10517 | This prepr ocessor wa s implemen ted to all ow HCCH to forward e lectronic secondary claims to additional payers by making th e addition al clearin ghouse’s n etworks av ailable to the VA. U nder this process th e VA would send the claim to H CCH. HCCH would then forward t he claim t o addition al clearin ghouse. Th e clearing house will submit th e claim to the final payer. | |
| 10518 | User Param eters | |
| 10519 | Preprocess or control page: C onfigure V alid Clear inghouse I Ds | |
| 10520 | Field Name | |
| 10521 | VistA 432 | |
| 10522 | X12 Locati on | |
| 10523 | Value | |
| 10524 | Clearingho use ID | |
| 10525 | CI5 – 3 | |
| 10526 | 2010BB NM1 09 | |
| 10527 | TPA payer ID | |
| 10528 | Claim Offi ce ID | |
| 10529 | N/A | |
| 10530 | N/A | |
| 10531 | Assigned b y TPA | |
| 10532 | ||
| 10533 | Functional Requireme nts | |
| 10534 | F REQ-1: R emove the Clearingho use ID if used on a Primary Cl aim | |
| 10535 | Determine whether th e followin g statemen ts are tru e: | |
| 10536 | Payer ID ( CI5 - 3 / 2010BB NM1 09) is equ al to clea ringhouse payer ID i n the clea ringhouse ID table | |
| 10537 | Payer Resp onsibility Sequence (CI2 - 2 / 2000B SBR 01) is equ al to P | |
| 10538 | If both st atements a re true, t hen perfor m the foll owing step s: | |
| 10539 | Delete Pay er ID (CI5 - 3 / 201 0BB NM109) | |
| 10540 | Delete Pay er ID qual ifier (CI5 - 2 / 201 0BB NM108) | |
| 10541 | If the fir st seconda ry claim I D qualifie r (CI5 - 4 / 2010BB REF01) is equal to F Y, then de lete the f irst secon dary claim ID qualif ier (CI5 - 4 / 2010B B REF01) a nd the fir st seconda ry ID (CI5 - 5 / 201 0BB REF02) | |
| 10542 | If the sec ond second ary claim ID qualifi er (CI5 - 6 / 2010BB REF01) is equal to FY, then d elete the second sec ondary cla im ID qual ifier (CI5 - 6 / 201 0BB REF01) and the s econd seco ndary ID ( CI5 - 7 / 2010BB REF 02) | |
| 10543 | If the thi rd seconda ry claim I D qualifie r (CI5 - 8 / 2010BB REF01) is equal to F Y, then de lete the s econd seco ndary clai m ID quali fier (CI5 - 8 / 2010 BB REF01) and the se cond secon dary ID (C I5 - 9 / 2 010BB REF0 2) | |
| 10544 | F REQ-2: V alidate th e claim of fice ID fo r the Paye r ID | |
| 10545 | Determine whether th e followin g statemen t is true: | |
| 10546 | Payer ID ( CI5 - 3 / 2010BB NM1 09) is equ al to clea ringhouse payer ID i n the clea ringhouse table | |
| 10547 | If true, t hen do per form the f ollowing s teps: | |
| 10548 | If the cla im office ID in the first seco ndary ID ( CI5 - 5 / 2010BB REF 02 where C I5-4 / 201 0BB REF01 = FY) is n ot equal t o one of t he claim o ffice IDs for the cl earinghous e ID, then delete: | |
| 10549 | Destinatio n payer ID qualifier (CI5 - 2 / 2010BB N M108) | |
| 10550 | Destinatio n payer ID (CI5 - 3 / 2010BB N M109) | |
| 10551 | First seco ndary clai m ID quali fier (CI5 - 4 / 2010 BB REF01) | |
| 10552 | First seco ndary ID ( CI5 - 5 / 2010BB REF 02) | |
| 10553 | If the cla im office ID in the second sec ondary ID qualifier (CI5 - 7 / 2010BB RE F02 where CI5-4 / 20 10 REF01 = FY) is no t equal to one of th e claim of fice IDs f or the cle aringhouse ID, then delete: | |
| 10554 | Destinatio n payer ID qualifier (CI5 - 2 / 2010BB N M108) | |
| 10555 | Destinatio n payer ID (CI5 - 3 / 2010BB N M109) | |
| 10556 | Second sec ondary cla im ID qual ifier (CI5 - 6 / 201 0BB REF01) | |
| 10557 | Second sec ondary ID (CI5 - 7 / 2010BB RE F02) | |
| 10558 | Site Focus Testing | |
| 10559 | Program Na me: EndTo EndTesting ID.exe | |
| 10560 | Overview | |
| 10561 | This page defines pa yers which are in fo cus testin g. If a cl aim is sub mitted to a payer li sted below from a si te with th e correspo nding tax ID and is within the date span listed, t he claim w ill be for warded to the 5010 p ayer switc h with the destinati on payer I D submitte d by the s ite. If th e claim is submitted from a si te not lis ted on the table or is outside the date range, the destinati on payer I D will be changed to IPRNT for instituti onal claim s or PPRNT for profe ssional cl aims. | |
| 10562 | The payer ID must al so be appr oved for s econdary c laims usin g the conf igure paye r screen. | |
| 10563 | After focu s test is complete, the payer ID should be removed from this table. If the test is unsucce ssful, the n it shoul d also be removed fr om list of valid sec ondary IDs . | |
| 10564 | Business C ase | |
| 10565 | When the V A sends a secondary claim to H CCH, HCCH either pri nts the cl aim on a p aper claim form or t ransmits i t electron ically to the final payer. The re are a l imited num ber of pay ers that a ccept elec tronic sec ondary cla ims from t he VA. If a secondar y claim is submitted for one o f the paye rs that is not desig nated as a pproved fo r the seco ndary clai ms, the FS C inserts a value (P PRNT or IP RNT) into the destin ation paye r ID (CI5 – 3 / 2010 BB NM109) which forc es the cla im to prin t on a pap er claim f orm. | |
| 10566 | This prepr ocessor al lows CBO t o designat e a limite d number o f sites th at can sub mit electr onic secon dary claim s to a spe cific paye r while th e rest of the sites continue t o be proce ssed on pa per claims forms. Th is change is used to verify th at the pay er will co rrectly pr ocess elec tronic sec ondary cla ims where secondary claim test ing was no t complete d satisfac torily. It creates a n alpha an d beta sit e testing for the pa yer and se condary cl aims. | |
| 10567 | User Param eters | |
| 10568 | Preprocess or control page: Con figure Pay er End to End Testin g | |
| 10569 | Field Name | |
| 10570 | VistA 432 | |
| 10571 | X12 Locati on | |
| 10572 | Value | |
| 10573 | Payer Name | |
| 10574 | CI1-2 | |
| 10575 | 2010BB NM1 03 | |
| 10576 | This value is not re ferenced i n the prep rocessor l ogic | |
| 10577 | Payer ID | |
| 10578 | CI5-3 | |
| 10579 | 2010BB NM1 09 | |
| 10580 | HCCH payer ID | |
| 10581 | Insurance Sequence | |
| 10582 | CI2-2 | |
| 10583 | 2000B SBR0 1 | |
| 10584 | S – Second ary | |
| 10585 | T – Tertia ry | |
| 10586 | Tax ID | |
| 10587 | CI1A-5 | |
| 10588 | 2010AA REF 02 | |
| 10589 | Site tax I D | |
| 10590 | First Test Date | |
| 10591 | N/A | |
| 10592 | N/A | |
| 10593 | Date claim is sent t o FSC | |
| 10594 | Last Test Date | |
| 10595 | N/A | |
| 10596 | N/A | |
| 10597 | Date claim is sent t o FSC | |
| 10598 | Create By | |
| 10599 | N/A | |
| 10600 | N/A | |
| 10601 | User who c reated ent ry | |
| 10602 | Functional Requireme nts | |
| 10603 | F REQ-1: R eplace pay er ID with PPRNT or IPRNT if n ot from te st site | |
| 10604 | Determine if the fol lowing sta tements ar e true: | |
| 10605 | The claim’ s payer ID (CI5 - 3 / 2010BB N M109) is a payer ID on the tab le | |
| 10606 | The billin g provider tax ID (C I1A - 5 / 2010AA REF 02) is not a tax ID listed for the payer ID | |
| 10607 | The claim submission date is b etween the start and end date on the tab le | |
| 10608 | The insura nce sequen ce (CI2 – 2 / 2000B SBR01) is equal to i nsurance s equence va lue | |
| 10609 | If all sta tements ar e true, th en: | |
| 10610 | Change the (CI5 - 3 / 2010BB N M109) to I PRNT on in stitutiona l claims | |
| 10611 | Change the (CI5 - 3 / 2010BB N M109) to P PRNT on pr ofessional claims | |
| 10612 | Payer ID S witch | |
| 10613 | Program Na me: PayerI Dswitches. exe | |
| 10614 | Overview | |
| 10615 | This prepr ocessor ch anges the destinatio n payer ID (CI5 – 3 / 2010BB N M109) if t he claim i s not a pr imary paye r claim. T he values for the de stination payer ID c an be conf igured dif ferently i f the prev ious payer ID is Med icare and also allow s a Third Party Admi nistrator (TPA) clai m office I D to be su bmitted as a seconda ry payer I D number. | |
| 10616 | Business C ase | |
| 10617 | This progr am address es several business issues rel ating to p ayer ID: | |
| 10618 | Payers hav e establis hed unique destinati on payer I Ds that ar e differen t based on if the cl aim is pri mary or se condary. | |
| 10619 | Medicare s econdary c laims shou ld be rout ed to a di fferent lo cation tha n non-Medi care secon dary claim s; this is done usin g the paye r ID | |
| 10620 | Claims whi ch are to be routed to Third P arty Admin istered (T PA) Cleari nghouses m ust includ e the TPA ID as the payer ID a nd a claim office ID number to identify the payer. | |
| 10621 | User Param eters | |
| 10622 | Preprocess or control page: Con figure Pay er | |
| 10623 | This page is also us ed by to s et X12 out bound clai m version. See 3.2. | |
| 10624 | Field Name | |
| 10625 | VistA 432 | |
| 10626 | X12 Locati on | |
| 10627 | Value | |
| 10628 | Payer Name | |
| 10629 | CI1-2 | |
| 10630 | 2010BB NM1 03 | |
| 10631 | This value is not re ferenced i n the prep rocessor l ogic | |
| 10632 | Primary ID | |
| 10633 | CI5- 3 | |
| 10634 | 2010BB NM1 09 | |
| 10635 | HCCH payer ID | |
| 10636 | Primary cl aims X12 V ersion | |
| 10637 | N/A | |
| 10638 | N/A | |
| 10639 | Used to se t outbound claim ver sion | |
| 10640 | 837 Claim Type | |
| 10641 | N/A | |
| 10642 | N/A | |
| 10643 | Profession al | |
| 10644 | Institutio nal | |
| 10645 | Profession al and Ins titutional | |
| 10646 | Unknown | |
| 10647 | Medicare s econdary c laims prim ary ID | |
| 10648 | CI5-3 | |
| 10649 | 2010BB NM1 09 | |
| 10650 | HCCH payer ID | |
| 10651 | Medicare s econdary c laims seco ndary ID | |
| 10652 | CI5-5 or C I5-7 | |
| 10653 | 2010BB REF 02 | |
| 10654 | Value used by TPA to route cla ims. Can b e sent in either the first or second ins tance of t he REF | |
| 10655 | Non-Medica re seconda ry claims | |
| 10656 | CI5 – 3 | |
| 10657 | 2010BB NM1 09 | |
| 10658 | HCCH payer ID | |
| 10659 | Functional Requireme nts | |
| 10660 | F REQ-1: V alidate de stination payer prim ary IDs on primary c laims | |
| 10661 | If payer s equence (C I2 – 2 / 2 000B SBR01 ) is “P,” then: | |
| 10662 | If destina tion payer ID (CI5 - 3 / 2010B B NM109) i s null, do nothing | |
| 10663 | If destina tion payer ID (CI5 - 3 / 2010B B NM109) i s in prima ry ID colu mn, then d o nothing | |
| 10664 | If destina tion payer ID (CI5 - 3 / 2010B B NM109) i s not in p rimary ID column, th en set des tination p ayer ID qu alifier (C I5 - 2 / 2 010BB NM10 8) and des tination p ayer ID (C I5 - 3 / 2 010BB NM10 9) to null | |
| 10665 | F REQ-2: V alidate de stination payer prim ary IDs on secondary professio nal claims where Med icare was the primar y payer | |
| 10666 | If receive r ID (GEN – 6) is “E NVOYP” or “CHAMVP” a nd if (CI2 – 2 / 200 0B SBR01) is “S” and other pay er ID (OI6 – 4 / 233 0B NM109) is “SMTX1” or “12M16 ” where ot her payer sequence ( OI6 – 2) i s “P”: | |
| 10667 | If destina tion payer ID (CI5 - 3 / 2010B B NM109) i s in the M edicare se condary ID column wh ere the cl aim type i s “P,” the n do nothi ng | |
| 10668 | If the des tination p ayer ID (C I5 - 3 / 2 010BB NM10 9) is in t he primary column wh ere the cl aim type i s “P” and the Medica re seconda ry column is not nul l and the TPA column is null, then set d estination payer ID (CI5 - 3 / 2010BB NM 109) equal to the Me dicare sec ondary val ue | |
| 10669 | If the des tination p ayer ID (C I5 - 3 / 2 010BB NM10 9) is in t he primary column wh ere the cl aim type i s “P” and the Medica re seconda ry column is not nul l and the TPA column is not nu ll, then s et destina tion payer ID (CI5 - 3 / 2010B B NM109) e qual to th e Medicare secondary value and : | |
| 10670 | If CI5 - 5 is null t hen set CI 5 - 4 equa l to “FY” and the CI 5 - 5 equa l to the T PA value | |
| 10671 | If CI5 - 5 is not nu ll then se t CI5 - 6 to “FY” an d the CI5 - 7 to the TPA value | |
| 10672 | If none of the condi tions are true, then set desti nation pay er ID qual ifier (CI5 – 2 / 201 0BB NM108) to “PI” a nd destina tion payer ID (CI5 - 3 / 2010B B NM109) t o “PPRNT” | |
| 10673 | F REQ-3: V alidate de stination payer prim ary IDs on tertiary profession al claims where Medi care was t he seconda ry payer | |
| 10674 | If receive r ID (GEN – 6) is “E NVOYP” or “CHAMVP” a nd if Paye r Responsi bility Seq uence (CI2 - 2 / 200 0B SBR01) is “T” and other pay er ID (OI6 – 4 / 233 0B NM109) is “SMTX1” or “12M16 ” where ot her payer sequence ( OI6 – 2) i s “S,” the n: | |
| 10675 | If the des tination p ayer ID (C I5 - 3 / 2 010BB NM10 9) is in t he Medicar e secondar y ID colum n where th e claim ty pe is “P” then do no thing | |
| 10676 | If the des tination p ayer ID (C I5 - 3 / 2 010BB NM10 9) is in t he primary column wh ere the cl aim type i s “P” and the Medica re seconda ry column is not nul l and the TPA column is null, then set d estination payer ID (CI5 - 3 / 2010BB NM 109) equa l to the M edicare se condary va lue | |
| 10677 | If the des tination p ayer ID (C I5 - 3 / 2 010BB NM10 9) is in the primar y column w here the c laim type is “P” and the Medic are second ary column is not nu ll and the TPA colum n is not n ull, then set destin ation paye r ID (CI5 - 3 / 2010 BB NM109) equal to t he Medicar e secondar y value an d: | |
| 10678 | If CI5 - 5 is null t hen set CI 5 - 4 equa l to “FY” and the CI 5 - 5 equa l to the T PA value | |
| 10679 | If CI5 - 5 is not nu ll then se t CI5 - 6 to “FY” an d the CI5 - 7 to the TPA value | |
| 10680 | If none of the condi tions are true then set destin ation paye r ID quali fier (CI5 – 2 / 2010 BB NM108) to “PI” an d destinat ion payer ID (CI5 - 3 / 2010BB NM109) t o “PPRNT” | |
| 10681 | F REQ-4: V alidate de stination payer prim ary IDs on secondary instituti onal claim s where Me dicare was the prima ry payer | |
| 10682 | If receive r ID (GEN – 6) is “E NVOYH” or “CHAMVH” a nd if Paye r Responsi bility Seq uence (CI2 - 2 / 200 0B SBR01) is “S” and other pay er ID (OI6 – 4 / 233 0B NM109) is “SMTX1” or “12M16 ” where ot her payer sequence ( OI6 – 2) i s “P”: | |
| 10683 | If the des tination p ayer ID (C I5 - 3 / 2 010BB NM10 9) is in t he Medicar e secondar y ID colum n where th e claim ty pe is “I” then do no thing | |
| 10684 | If the des tination p ayer ID (C I5 - 3 / 2 010BB NM10 9) is in t he primary column wh ere the cl aim type i s “I” and the Medica re seconda ry column is not nul l and the TPA column is null, then set d estination payer ID (CI5 - 3 / 2010BB NM 109) equal to the Me dicare sec ondary val ue | |
| 10685 | If the des tination p ayer ID (C I5 - 3 / 2 010BB NM10 9) is in t he primary column wh ere the cl aim type i s “I” and the Medica re seconda ry column is not nul l and the TPA column is not nu ll, then s et destina tion payer ID (CI5 - 3 / 2010B B NM109) e qual to th e Medicare secondary value and : | |
| 10686 | If destina tion payer ID (CI5 - 3 / 2010B B NM109) i s null the n set CI5 - 4 equal to “FY” an d the CI5 - 5 equal to the TPA value | |
| 10687 | If destina tion payer ID (CI5 - 3 / 2010B B NM109) i s not null then set CI5 - 6 to “FY” and the CI5 - 7 to the T PA value | |
| 10688 | If none of the condi tions are true then set destin ation paye r ID quali fier (CI5 - 2 / 2010 BB NM108) to “PI” an d destinat ion payer ID (CI5 - 3 / 2010BB NM109) to “IPRNT” | |
| 10689 | F REQ-5: V alidate de stination payer prim ary IDs on tertiary claims whe re Medicar e was the secondary payer | |
| 10690 | If receive r ID (GEN – 6) is “E NVOYH” or “CHAMVH” a nd if Paye r Responsi bility Seq uence (CI2 - 2 / 200 0B SBR01) is “T” and other pay er ID (OI6 – 4 / 233 0B NM109) is “SMTX1” or “12M16 ” where ot her payer sequence ( OI6 – 2) i s “S,” the n: | |
| 10691 | If the des tination p ayer ID (C I5 - 3 / 2 010BB NM10 9) is in t he Medicar e secondar y ID colum n where th e claim ty pe is “I” then do no thing | |
| 10692 | If the des tination p ayer ID (C I5 - 3 / 2 010BB NM10 9) is in t he primary column wh ere the cl aim type i s “I” and the Medica re seconda ry column is not nul l and the TPA column is null, then set d estination payer ID (CI5 - 3 / 2010BB NM 109) equal to the Me dicare sec ondary val ue | |
| 10693 | If the des tination p ayer ID (C I5 - 3 / 2 010BB NM10 9) is in t he primary column wh ere the cl aim type i s “I” and the Medica re seconda ry column is not nul l and the TPA column is not nu ll, then s et destina tion payer ID (CI5 - 3 / 2010B B NM109) e qual to th e Medicare secondary value | |
| 10694 | and | |
| 10695 | If CI5 - 5 is null t hen set CI 5 - 4 equa l to “FY” and the CI 5 - 5 equa l to the T PA value | |
| 10696 | If CI5 - 5 is not nu ll then se t CI5 - 6 to “FY” an d the CI5 - 7 to the TPA value | |
| 10697 | If none of the condi tions are true then set destin ation paye r ID quali fier (CI5 - 2 / 2010 BB NM108) to “PI” an d destinat ion payer ID (CI5 - 3 / 2010BB NM109) to “IPRNT” | |
| 10698 | F REQ-6: D o not act on destina tion payer IDs for n on-primary claims if Medicare is not imm ediately s econdary | |
| 10699 | If receive r ID (GEN – 6) is “E NVOYH” or “CHAMVH” a nd if Paye r Responsi bility Seq uence (CI2 - 2 / 200 0B SBR01) is “S” and OI6 - 4 i s not “SMT X1” or “12 M16” where OI6 - 2 i s “P,” the n do nothi ng | |
| 10700 | If receive r ID (GEN – 6) is “E NVOYH” or “CHAMVH” a nd if Paye r Responsi bility Seq uence (CI2 - 2 / 200 0B SBR01) is “T” an d OI6 - 4 is not “SM TX1” or “1 2M16” wher e OI6 - 2 is “S,” th en do noth ing | |
| 10701 | If receive r ID (GEN – 6) is “E NVOYP” or “CHAMVP” a nd if Paye r Responsi bility Seq uence (CI2 - 2 / 200 0B SBR01) is “S” and OI6 - 4 i s not “SMT X1” or “12 M16” where OI6 - 2 i s “P,” the n do nothi ng | |
| 10702 | If receive r ID (GEN – 6) is “E NVOYP” or “CHAMVP” a nd if Paye r Responsi bility Seq uence (CI2 - 2 / 200 0B SBR01) is “T” and OI6 - 4 i s not “SMT X1” or “12 M16” where OI6 - 2 i s “S,” the n do nothi ng | |
| 10703 | Set X12 Ou tbound Cla im Version | |
| 10704 | Program Na me: Versi on4010Spli tter.exe, RemoveDown gradedReco rds.exe | |
| 10705 | Overview | |
| 10706 | This prepr ocessor ro utes the c laim data to 5010 Er rata map b ased on th e destinat ion payer ID (CI5 -3 / 2010BB NM109). Al l preproce ssors whic h alter th e destinat ion claim ID value m ust execut e before t his step. | |
| 10707 | Business C ase | |
| 10708 | Allow the VA to send claims to the HCCH in the 501 0 errata v ersion of the X12 st andard in order to m anage the transition between t he standar ds. | |
| 10709 | User Param eters | |
| 10710 | Preprocess or control page: Con figure Pay er | |
| 10711 | This page is also us ed to chan ge payer I Ds for non -primary c laims. See 3.1 | |
| 10712 | Field Name | |
| 10713 | VistA 432 | |
| 10714 | X12 Locati on | |
| 10715 | Value | |
| 10716 | Payer Name | |
| 10717 | CI1-2 | |
| 10718 | 2010BB NM1 03 | |
| 10719 | This value is not re ferenced i n the prep rocessor l ogic | |
| 10720 | Primary ID | |
| 10721 | CI5-3 | |
| 10722 | 2010BB NM1 09 | |
| 10723 | HCCH payer ID | |
| 10724 | Primary cl aims X12 v ersion | |
| 10725 | N/A | |
| 10726 | N/A | |
| 10727 | Outbound c laim versi on on prim ary claims | |
| 10728 | 837 Claim Type | |
| 10729 | N/A | |
| 10730 | N/A | |
| 10731 | Profession al | |
| 10732 | Institutio nal | |
| 10733 | Profession al and Ins titutional | |
| 10734 | Unknown | |
| 10735 | Secondary claims X12 version | |
| 10736 | N/A | |
| 10737 | N/A | |
| 10738 | Outbound c laim versi on on seco ndary and tertiary c laims | |
| 10739 | Medicare s econdary c laims prim ary ID | |
| 10740 | CI5-3 | |
| 10741 | 2010BB NM1 09 | |
| 10742 | HCCH payer ID See 3. 1 | |
| 10743 | Medicare s econdary c laims seco ndary ID | |
| 10744 | CI5-5 or C I5-7 | |
| 10745 | 2010BB REF | |
| 10746 | Value used by TPA to route cla ims. See 3 .1 | |
| 10747 | Non-Medica re seconda ry claims | |
| 10748 | CI5-3 | |
| 10749 | 2010BB NM1 09 | |
| 10750 | HCCH payer ID See 3. 1 | |
| 10751 | Functional Requireme nts | |
| 10752 | F REQ-1: M ove primar y claims i nto 5010 o utbound fi le | |
| 10753 | If the Pay er Respons ibility Se quence (CI 2 - 2 / 20 00B SBR01) is equal to P, then determine if the fo llowing st atement is true: | |
| 10754 | Is the val ue in the Payer Cont rol table = 5010 whe re: | |
| 10755 | The destin ation paye r primary ID (CI5 – 3 / 2010BB NM109) is equals th e value fo r in the p rimary ID column | |
| 10756 | The value for Claim Type is eq ual to the claim: | |
| 10757 | Claim Type is “Insti tutional” and receiv er ID (GEN – 6) is “ ENVOYH” or “PARTA” o r “CHAMVH. ” | |
| 10758 | Claim Type is “Profe ssional” a nd receive r ID (GEN – 6) is “E NVOYP”” or “PARTB” o r “CHAMVP” | |
| 10759 | If Claim T ype is “In st and Pro f,” always return tr ue for thi s conditio n | |
| 10760 | If true, t hen copy a ll records relating to the cla im into a 5010 holdi ng file in cluding th e BGN and GEN record s. | |
| 10761 | F REQ-2: M ove non-pr imary clai ms into th e 5010 fil e | |
| 10762 | If the pay er sequenc e value (C I2 - 2 / 2 000B SBR01 ) is not e qual to P, then dete rmine if t he followi ng stateme nt is true : | |
| 10763 | Is the val ue in the Payer Cont rol table = 5010 whe re: | |
| 10764 | The destin ation paye r primary ID (CI5 – 3 / 2010BB NM109) is equal to a value in the secon dary ID co lumn. Colu mn for Med icare or n on-Medicar e claims. | |
| 10765 | The value for Claim Type is eq ual to the claim: | |
| 10766 | Claim Type is “Insti tutional” and receiv er ID (GEN – 6) is “ ENVOYH” or “PARTA” o r “CHAMVH” | |
| 10767 | Claim Type is “Profe ssional” a nd receive r ID (GEN – 6) is “E NVOYP”” or “PARTB” o r “CHAMVP” | |
| 10768 | If Claim T ype is “In st and Pro f,” always return tr ue for thi s conditio n | |
| 10769 | If true, t hen copy a ll records relating to the cla im into a 5010 holdi ng file in cluding th e BGN and GEN record s. | |
| 10770 | F REQ-3: M ove non-de fined clai ms into th e 5010 fil e | |
| 10771 | If the ID does not m atch a val ue in the table, the n move it to the 501 0 file. | |
| 10772 | Remove NPI from Medi care claim s | |
| 10773 | Program Na me: Remov eNPI.exe | |
| 10774 | Overview | |
| 10775 | This progr am removes all Natio nal Provid er ID numb ers (NPI) from claim s submitte d to Medic are. | |
| 10776 | Business C ase | |
| 10777 | Medicare A dministrat ive Contra ctor canno t process VA claims when submi tted with NPI number . | |
| 10778 | User Param eters – N/ A | |
| 10779 | Functional Requireme nts | |
| 10780 | F REQ-1: R emove NPI numbers fr om Medicar e claims | |
| 10781 | If the des tination p ayer ID (C I5 – 3 / 2 010BB NM10 9) is equa l to SMTX1 or 12M61 (Medicare) , then del ete the fo llowing re cords and fields: | |
| 10782 | PRV - 9 an d 12 Billi ng provide r NPI (837 P 2010AA; 837I 2010A A) | |
| 10783 | PRV1 - 5 a nd 6 pay t o provider NPI (4010 only) | |
| 10784 | SUB2 - 5 a nd 6 Lab f acility NP I (837P 23 10C; 837I 2310E) | |
| 10785 | OPR1 - 2 a nd 3 Atten ding provi der NPI (8 37I 2310A) | |
| 10786 | OPR1 - 5 a nd 6 Other operating provider NPI (837I 2310C) | |
| 10787 | OPR1 - 8 a nd 9 Opera ting physi cian NPI ( 837I 2310B ) | |
| 10788 | OPR1 - 11 and 12 Ref erring pro vider NPI (837P 2310 A; 837I 23 10F) | |
| 10789 | OPR7 - 6 a nd 7 Super vising pro vider NPI (837P 2310 D) | |
| 10790 | OPR9 - 8 a nd 9 Rende ring provi der NPI (8 37I 2310D; 837P 2310 B) | |
| 10791 | LOPE - 8 a nd 9 Line level oper ating phys ician NPI (837I 2420 A) | |
| 10792 | LOP1 - 8 a nd 9 Line level othe r operatin g physicia n NPI(837I 2420B) | |
| 10793 | LREN - 8 a nd 9 Line level rend ering prov ider NPI ( 837I 2420C ; 837P 242 0A) | |
| 10794 | LPUR - 4 a nd 5 Line level purc hase servi ce provide r NPI (837 P 2420B) | |
| 10795 | LSUP - 8 a nd 9 Line level supe rvising pr ovider NPI (837P 242 0D) | |
| 10796 | LREF - 8 a nd 9 Line level refe rring prov ider NPI ( 837I 2420D ; 837P 242 0F) | |
| 10797 | Remove AB3 | |
| 10798 | Program Na me: Remov eAB3.exe | |
| 10799 | Overview | |
| 10800 | This progr am removes the adjus tment reas on codes o f AB3 and associated amounts w hen not su bmitted on a paper M edicare in stitutiona l secondar y claims. (Payer ID is equal t o IPRNT.) | |
| 10801 | Business C ase | |
| 10802 | The AB3 va lue is use d by HCCH for printi ng MRA fil es. It sho uld only a ppear on c laims with the IPRNT IDs. | |
| 10803 | User Param eters – N/ A | |
| 10804 | Functional Requireme nts | |
| 10805 | F REQ-1: I f the dest ination pa yer ID (CI 5 – 3 / 20 10BB NM109 ) is equal to IPRNT, then do n othing. | |
| 10806 | F REQ-2: I f the dest ination pa yer ID (CI 5 – 3 / 20 10BB NM109 ) is not e qual to IP RNT then: | |
| 10807 | If adjustm ent reason code 1 (C CAS – 4 / 2320 CAS02 ) is equal to AB3, t hen: | |
| 10808 | Delete adj ustment re ason code 1 (CCAS – 4 / 2320 C AS02) adju stment amo unt 1 (CCA S – 5 / 23 20 CAS03), and adjus tment quan tity 1 (CC AS – 6 / 2 320 CAS04) . | |
| 10809 | If adjustm ent reason code 2 (C CAS – 7 / 2320 CAS05 ) then del ete the en tire CCAS record | |
| 10810 | If adjustm ent reason 2 (CCAS – 7 / 2320 CAS05) is not null, then: | |
| 10811 | Move adjus tment 2 in to adjustm ent 1 | |
| 10812 | Move adjus tment 3 in to adjustm ent 2 | |
| 10813 | Move adjus tment 4 in to adjustm ent 3 | |
| 10814 | Move adjus tment 5 in to adjustm ent 4 | |
| 10815 | Move adjus tment 6 in to adjustm ent 5 | |
| 10816 | If adjustm ent reason code 2 (C CAS – 7 / 2320 CAS05 ) is equal to AB3, t hen: | |
| 10817 | Delete adj ustment re ason code 2 (LCAS – 7 / 2320 C AS05) adju stment amo unt 2 (CCA S – 8 / 23 20 CAS06), and adjus tment quan tity 2 (CC AS – 9 / 2 320 CAS07) . | |
| 10818 | If adjustm ent reason 3 (CCAS – 10 / 2320 CAS08) is not null, then: | |
| 10819 | Move adjus tment 3 in to adjustm ent 2 | |
| 10820 | Move adjus tment 4 in to adjustm ent 3 | |
| 10821 | Move adjus tment 5 in to adjustm ent 4 | |
| 10822 | Move adjus tment 6 in to adjustm ent 5 | |
| 10823 | If adjustm ent reason code 3 (C CAS – 10 / 2320 CAS0 8) is equa l to AB3, then: | |
| 10824 | Delete adj ustment re ason code 3 (CCAS – 10 / 2320 CAS08) adj ustment am ount 3 (CC AS – 11 / 2320 CAS09 ), and adj ustment qu antity 3 ( CCAS – 12 / 2320 CAS 10). | |
| 10825 | If adjustm ent reason 4 (CCAS – 13 / 2320 CAS11) is not null, then: | |
| 10826 | Move adjus tment 4 in to adjustm ent 3 | |
| 10827 | Move adjus tment 5 in to adjustm ent 4 | |
| 10828 | Move adjus tment 6 in to adjustm ent 5 | |
| 10829 | If adjustm ent reason code 4 (C CAS – 13 / 2320 CAS1 1) is equa l to AB3, then: | |
| 10830 | Delete adj ustment re ason code 4 (CCAS – 13 / 2320 CAS11) adj ustment am ount 3 (CC AS – 14 / 2320 CAS12 ), and adj ustment qu antity 3 ( CCAS - 15, 2320 CAS1 3). | |
| 10831 | If adjustm ent reason 5 (CCAS – 16 / 2320 CAS14) is not null, then: | |
| 10832 | Move adjus tment 5 in to adjustm ent 4 | |
| 10833 | Move adjus tment 6 in to adjustm ent 5 | |
| 10834 | If adjustm ent reason code 5 (C CAS – 16 / 2320 CAS1 4) is equa l to AB3, then: | |
| 10835 | Delete adj ustment re ason code 5 (CCAS – 16 / 2320 CAS14) adj ustment am ount 5 (CC AS – 17 / 2320 CAS15 ), and adj ustment qu antity 5 ( CCAS – 18 / 2320 CAS 16). | |
| 10836 | If adjustm ent reason 6 (LCAS – 19 / 2430 CAS17) is not null, then: | |
| 10837 | Move adjus tment 6 in to adjustm ent 5 | |
| 10838 | If adjustm ent reason code 6 (L CAS – 19 / 2430 CAS1 7) is equa l to AAA, then: | |
| 10839 | Delete adj ustment re ason code 6 (LCAS – 19 / 2430 CAS17) adj ustment am ount 6 (LC AS – 20 / 2430 CAS18 ), and adj ustment qu antity 6 ( LCAS – 21 / 2430 CAS 19). | |
| 10840 | Remove LQ | |
| 10841 | Program Na me: Remov eLQ.exe | |
| 10842 | Overview | |
| 10843 | This progr am removes the adjus tment reas on codes o f LQ and a ssociated amounts wh en not sub mitted on a paper Me dicare sec ondary cla ims. (Paye r ID is eq ual to IPR NT or PPRN T.) | |
| 10844 | Business C ase | |
| 10845 | The LQ val ue is used by HCCH f or printin g MRA file s. It shou ld only ap pear on cl aims with the IPRNT and PPRNT IDs. | |
| 10846 | User Param eters – N/ A | |
| 10847 | Functional Requireme nts | |
| 10848 | F REQ-1: I f the dest ination pa yer ID (CI 5 – 3 / 20 10BB NM109 ) is equal to IPRNT or PPRNT, then do no thing. | |
| 10849 | F REQ-2: I f the dest ination pa yer ID (CI 5 – 3 / 20 10BB NM109 ) is not e qual to IP RNT or PPR NT and the Claim Adj ustment Gr oup Code ( LCAS – 3 / 2320 CAS0 1) is equa l to LQ, t hen delete the entir e LCAS seg ment | |
| 10850 | Remove AAA | |
| 10851 | Program Na me: Remov eAAA.exe | |
| 10852 | Overview | |
| 10853 | This progr am removes the adjus tment reas on codes o f AAA and associated amounts w hen not su bmitted on a paper M edicare se condary cl aims. | |
| 10854 | Business C ase | |
| 10855 | The AAA va lue is use d by HCCH for printi ng MRA fil es. It sho uld only a ppear on c laims with the IPRNT or PPRNT IDs. | |
| 10856 | User Param eters – N/ A | |
| 10857 | Functional Requireme nts | |
| 10858 | F REQ-1: I f the dest ination pa yer ID (CI 5 - 3, 201 0BB NM109) is equal to IPRNT o r PPRNT, t hen do not hing. | |
| 10859 | F REQ-2: I f the dest ination pa yer ID (CI 5 - 3, 201 0BB NM109) is not eq ual to IPR NT or PPRN T, then: | |
| 10860 | If adjustm ent reason code 1 (L CAS – 4 / 2430 CAS02 ) is equal to AAA, t hen: | |
| 10861 | Delete adj ustment re ason code 1 (LCAS – 4 / 2430 C AS02) adju stment amo unt 1 (LCA S – 5 / 24 30 CAS03), and adjus tment quan tity 1 (LC AS – 6 / 2 430 CAS04) . | |
| 10862 | If adjustm ent reason code 2 (L CAS – 7 / 2430 CAS05 ) then del ete the en tire LCAS record | |
| 10863 | If adjustm ent reason 2 (LCAS – 7 / 2430 CAS05) is not null, then: | |
| 10864 | Move adjus tment 2 in to adjustm ent 1 | |
| 10865 | Move adjus tment 3 in to adjustm ent 2 | |
| 10866 | Move adjus tment 4 in to adjustm ent 3 | |
| 10867 | Move adjus tment 5 in to adjustm ent 4 | |
| 10868 | Move adjus tment 6 in to adjustm ent 5 | |
| 10869 | If adjustm ent reason code 2 (L CAS – 7 / 2430 CAS05 ) is equal to AAA, t hen: | |
| 10870 | Delete adj ustment re ason code 2 (LCAS – 7 / 2430 C AS05) adju stment amo unt 2 (LCA S – 8 / 24 30 CAS06), and adjus tment quan tity 2 (LC AS - 9 / 2 430 CAS07) . | |
| 10871 | If adjustm ent reason 3 (LCAS – 10 / 2430 CAS08) is not null, then: | |
| 10872 | Move adjus tment 3 in to adjustm ent 2 | |
| 10873 | Move adjus tment 4 in to adjustm ent 3 | |
| 10874 | Move adjus tment 5 in to adjustm ent 4 | |
| 10875 | Move adjus tment 6 in to adjustm ent 5 | |
| 10876 | If adjustm ent reason code 3 (L CAS – 10 / 2430 CAS0 8) is equa l to AAA, then: | |
| 10877 | Delete adj ustment re ason code 3 (LCAS – 10 / 2430 CAS08) adj ustment am ount 3 (LC AS – 11 / 2430 CAS09 ), and adj ustment qu antity 3 ( LCAS – 12 / 2430 CAS 10). | |
| 10878 | If adjustm ent reason 4 (LCAS – 13 / 2430 CAS11) is not null, then: | |
| 10879 | Move adjus tment 4 in to adjustm ent 3 | |
| 10880 | Move adjus tment 5 in to adjustm ent 4 | |
| 10881 | Move adjus tment 6 in to adjustm ent 5 | |
| 10882 | If adjustm ent reason code 4 (L CAS – 13 / 2430 CAS1 1) is equa l to AAA, then: | |
| 10883 | Delete adj ustment re ason code 4 (LCAS – 13 / 2430 CAS11) adj ustment am ount 3 (LC AS – 14 / 2430 CAS12 ), and adj ustment qu antity 3 ( LCAS – 15 / 2430 CAS 13). | |
| 10884 | If adjustm ent reason 5 (LCAS – 16 / 2430 CAS14) is not null, then: | |
| 10885 | Move adjus tment 5 in to adjustm ent 4 | |
| 10886 | Move adjus tment 6 in to adjustm ent 5 | |
| 10887 | If adjustm ent reason code 5 (L CAS – 16 / 2430 CAS1 4) is equa l to AAA, then: | |
| 10888 | Delete adj ustment re ason code 5 (LCAS – 16 / 2430 CAS14) adj ustment am ount 5 (LC AS – 17 / 2430 CAS15 ), and adj ustment qu antity 5 ( LCAS – 18 / 2430 CAS 16). | |
| 10889 | If adjustm ent reason 6 (LCAS – 19 / 2430 CAS17) is not null, then: | |
| 10890 | Move adjus tment 6 in to adjustm ent 5 | |
| 10891 | If adjustm ent reason code 6 (L CAS – 19 / 2430 CAS1 7) is equa l to AAA, then: | |
| 10892 | Delete adj ustment re ason code 6 (LCAS – 19 / 2430 CAS17) adj ustment am ount 6 (LC AS – 20 / 2430 CAS18 ), and adj ustment qu antity 6 ( LCAS – 21 / 2430 CAS 19) | |
| 10893 | Remove 2U | |
| 10894 | Program Na me: Remov e2U.exe | |
| 10895 | Overview | |
| 10896 | If a secon dary ID is sent in t he other p ayer loop with the 2 U qualifie r where Me dicare is the payer, this prog ram remove s both the ID and th e qualifie r. | |
| 10897 | Business C ase | |
| 10898 | This prepr ocess was created to satisfy a payer req uirement. The value 2U is not valid for the provid er seconda ry ID type when subm itting a M edicare pr imary clai m per the HIPAA impl ementation guides. S ome payers have adde d an edit to their s ystem whic h will rej ect a clai m if a 2U value is u sed as a p rovider se condary ID type on M edicare se condary cl aims. Whil e this edi t may not be in acco rdance wit h the HIPA A rules, i t was deci ded to rem ove the 2U from Medi care secon dary claim s to reduc e the over all reject ion rate r ather than attempt t o convince payers to remove th e edit. | |
| 10899 | User Param eters – N/ A | |
| 10900 | Functional Requireme nts | |
| 10901 | F REQ-1: R emove IDs submitted with 2U qu alifier wh ere Medica re Part A is the oth er payer | |
| 10902 | If the oth er insuran ce primary payer ID (OI6 – 4 / 2330B NM1 09) is equ al to 12M6 1 (Medicar e Part A), then: | |
| 10903 | If the fir st seconda ry ID qual ifier (OI6 record 5 / 2330B RE F01) is eq ual to 2U, delete th e first se condary ID qualifier (OI6 reco rd 5 / 233 0B REF01) and the fi rst second ary ID (OI 6 record 6 / 2330B R EF02) | |
| 10904 | If the sec ond second ary ID qua lifier (OI 6 record 7 / 2330B R EF01) is e qual to 2U , delete t he second secondary ID qualifi er (OI6 re cord 7 / 2 330B REF01 ) and the second sec ondary ID (OI6 recor d 8 / 2330 B REF02) | |
| 10905 | F REQ-2: R emove IDs submitted with 2U qu alifier wh ere Medica re Part B is the oth er payer | |
| 10906 | If the oth er insuran ce primary payer ID (OI6 – 4 / 2330B NM1 09) is equ al to SMTX 1 (Medicar e Part B), then: | |
| 10907 | If the fir st seconda ry ID qual ifier (OI6 record 5 / 2330B RE F01) is eq ual to 2U, delete th e first se condary ID qualifier (OI6 reco rd 5 / 233 0B REF01) and the fi rst second ary ID (OI 6 record 6 / 2330B R EF02) | |
| 10908 | If the sec ond second ary ID qua lifier (OI 6 record 7 / 2330B R EF01) is e qual to 2U , delete t he second secondary ID qualifi er (OI6 re cord 7 / 2 330B REF01 ) and the second sec ondary ID (OI6 recor d 8 / 2330 B REF02) | |
| 10909 | Default Se rvice Faci lity Addre ss | |
| 10910 | Program Na me: SvcFac ilityAddre ss.exe | |
| 10911 | Overview | |
| 10912 | If a claim is submit ted to one of the de stination payers in the user-d efined lis t and no s ervice fac ility info rmation is submitted on the cl aim, then the billin g provider informati on is dupl icated in the servic e facility loop. | |
| 10913 | Business C ase | |
| 10914 | Prior to p atch 400, claims sub mitted fro m VAMC alw ays contai ned a serv ice facili ty address . With the implement ation of p atch 400, the VAMC w on’t alway s be sendi ng the ser vice facil ity addres s. It was not known at the tim e of the i mplementat ion if the re were an y payers t hat requir e this inf ormation e ven though it is not HIPAA-com pliant. It was decid ed that in order to mitigate t he risk of claims re ceiving pa yer level claim reje cts, FSC w ould imple ment code to default this valu e if the p ayer expre ssly reque sted this data item. | |
| 10915 | User Param eters | |
| 10916 | Preprocess or control page: C onfigure S ervice Fac ility Paye r List | |
| 10917 | This page is also us ed to chan ge payer I Ds for non -primary c laims. See 3.1. | |
| 10918 | Field Name | |
| 10919 | VistA 432 | |
| 10920 | X12 Locati on | |
| 10921 | Value | |
| 10922 | Payer ID | |
| 10923 | CI5 – 3 | |
| 10924 | 2010BB NM1 09 | |
| 10925 | HCCH payer ID | |
| 10926 | Payer name | |
| 10927 | ||
| 10928 | 2010BB NM1 03 | |
| 10929 | Not used w ithin the program | |
| 10930 | Payer flag | |
| 10931 | N/A | |
| 10932 | N/A | |
| 10933 | A – All cl aims | |
| 10934 | B – If pla ce of serv ice is not home or o ffice | |
| 10935 | Functional Requireme nts | |
| 10936 | F REQ-1: C opy the bi lling prov ider into the servic e facility loop when payer fla g is A | |
| 10937 | Determine if the fol lowing sta tements ar e true: | |
| 10938 | If the cla im’s payer ID (CI5 – 3 / 2010B B NM109) i s a payer ID listed on the con trol page | |
| 10939 | The servic e facility name (SUB 2 - 4/ 231 0D NM103) is null | |
| 10940 | The player flag is A | |
| 10941 | If all sta tements ar e true, th en perform the follo wing steps : | |
| 10942 | Default va lue of 77 to record (SUB2 - 2 / 2310D NM 101) | |
| 10943 | Default va lue of 2 t o record ( SUB2 - 3 / 2310D NM1 02) | |
| 10944 | Copy the b illing pro vider name record (P RV - 3 / 2 010AA NM10 3) to serv ice facili ty name re cord (SUB - 2 / 2310 D NM103) | |
| 10945 | Copy the p rimary bil ling provi der number (PRV - 9 / 2010AA N M109) to t he primary service f acility nu mber (SUB2 - 6 / 231 0D NM109) and set pr imary serv ice ID qua lifier (SU B2 – 5 / 2 310D NM108 ) to XX | |
| 10946 | Copy billi ng provide r address line one r ecord (PRV - 4 / 201 0AA N301) to service facility provider a ddress (SU B - 3 / 23 10D N301) | |
| 10947 | Copy billi ng provide r address line two r ecord PRV - 11 (2010 AA N302) t o service facility p rovider ad dress line two (SUB – 12 / 231 0D N302) | |
| 10948 | Copy billi ng provide r city (PR V - 5 / 20 10AA N401) to servic e facility provider city (SUB – 4 / 2310 D N401) | |
| 10949 | Copy billi ng provide r state (P RV - 6 / 2 010AA N402 ) to servi ce facilit y provider state (SU B – 5 / 23 10D N402). | |
| 10950 | Copy billi ng provide r zip code (PRV - 7 / 2010AA N 403) to se rvice faci lity provi der zip co de (SUB – 6 / 2310D N403) | |
| 10951 | Copy the s econd bill ing provid er seconda ry ID qual ifier reco rd (CI1A - 4 / 2010A A REF01) t o the firs t service facility q ualifier r ecord (SUB 2 – 7 / 23 10D REF01) | |
| 10952 | Copy the s econd bill ing provid er seconda ry ID reco rd (CI1A - 5 / 2010A A REF02) t o the firs t billing provider s econdary I D record ( SUB2 - 8 / 2310D REF 02) | |
| 10953 | Copy the t hird billi ng provide r secondar y ID quali fier recor d (CI1A - 6 / 2010AA REF01) to the secon d service facility q ualifier r ecord (SUB 2 – 9 / 23 10D REF01) | |
| 10954 | Copy the t hird billi ng provide r secondar y ID recor d (CI1A - 7 / 2010AA REF02) to the secon d billing provider s econdary I D record ( SUB2 - 10 / 2310D RE F02) | |
| 10955 | Copy the f ourth bill ing provid er seconda ry ID qual ifier reco rd (CI1A - 8 / 2010A A REF01) t o the thir d service facility q ualifier r ecord (SUB 2 – 11 / 2 310D REF01 ) | |
| 10956 | Copy the f ourth bill ing provid er seconda ry ID reco rd (CI1A - 9 / 2010A A REF02) t o the thir d billing provider s econdary I D record ( SUB2 - 12 / 2310D RE F02) | |
| 10957 | F REQ-2: C opy the bi lling prov ider into the servic e facility loop when payer fla g is B | |
| 10958 | Determine if the fol lowing sta tements ar e true | |
| 10959 | If the cla im’s payer ID (CI5 – 3 / 2010B B NM109) i s a payer ID listed on the con trol page | |
| 10960 | The servic e facility name (SUB 2 - 4/ 231 0D NM103) is null | |
| 10961 | The player flag is B | |
| 10962 | The place of service (CL1 reco rd 33) is not equal to 11 or 1 2 | |
| 10963 | If all sta tements ar e true, th en do the following: | |
| 10964 | Default va lue of 77 to record (SUB2 - 2 / 2310D NM 101) | |
| 10965 | Default va lue of 2 t o record ( SUB2 - 3 / 2310D NM1 02) | |
| 10966 | Copy the b illing pro vider name record (P RV - 3 / 2 010AA NM10 3) to serv ice facili ty name re cord (SUB - 2 / 2310 D NM103) | |
| 10967 | Copy the p rimary bil ling provi der number (PRV - 9 / 2010AA N M109) to t he primary service f acility nu mber (SUB2 - 6 / 231 0D NM109) and set pr imary serv ice ID qua lifier (SU B2 - 5 / 2 310D NM108 ) to XX | |
| 10968 | Copy billi ng provide r address line one r ecord (PRV - 4 / 201 0AA N301) to service facility provider a ddress (SU B – 3 / 23 10D N301) | |
| 10969 | Copy billi ng provide r address line two r ecord (PRV - 11 / 20 10AA N302) to servic e facility provider address li ne two (SU B - 12 / 2 310D N302) | |
| 10970 | Copy billi ng provide r city (PR V - 5 / 20 10AA N401) to servic e facility provider city (SUB - 4 / 2310 D N401) | |
| 10971 | Copy billi ng provide r state (P RV - 6 / 2 010AA N402 ) to servi ce facilit y provider state (SU B - 5 / 23 10D N402) | |
| 10972 | Copy billi ng provide r zip code (PRV - 7 / 2010AA N 403) maps to service facility provider z ip code (S UB - 6 / 2 310D N403) | |
| 10973 | Copy the s econd bill ing provid er seconda ry ID qual ifier reco rd (CI1A - 4 / 2010A A REF01) t o the firs t service facility q ualifier r ecord (SUB 2 - 7 / 23 10D REF01) | |
| 10974 | Copy the s econd bill ing provid er seconda ry ID reco rd (CI1A - 5 / 2010A A REF02) t o the firs t billing provider s econdary I D record ( SUB2 - 8 / 2310D REF 02) | |
| 10975 | Copy the t hird billi ng provide r secondar y ID quali fier recor d (CI1A - 6 / 2010AA REF01) to the secon d service facility q ualifier r ecord (SUB 2 - 9 / 23 10D REF01) | |
| 10976 | Copy the t hird billi ng provide r secondar y ID recor d (CI1A - 7 / 2010AA REF02) to the secon d billing provider s econdary I D record ( SUB2 - 10 / 2310D RE F02) | |
| 10977 | Copy the f ourth bill ing provid er seconda ry ID qual ifier reco rd (CI1A - 8 / 2010A A REF01) t o the thir d service facility q ualifier r ecord (SUB 2 - 11 / 2 310D REF01 ) | |
| 10978 | Copy the f ourth bill ing provid er seconda ry ID reco rd (CI1A - 9 / 2010A A REF02) t o the thir d billing provider s econdary I D record ( SUB2 - 12 / 2310D RE F02) | |
| 10979 | Default Bi lling Addr ess | |
| 10980 | Program Na me: Defau ltBillingP roviderAdd ress.exe | |
| 10981 | Overview | |
| 10982 | If a claim is submit ted to a p ayer liste d in the t able below which inc ludes a pa y to addre ss (2010AB N3 and 20 10AB N4), then the p ay to addr ess replac es the bil ling addre ss (2010AA N3 and 20 10AA N4) i n the outb ound claim . | |
| 10983 | Business C ase | |
| 10984 | This prepr ocessor wa s implemen ted to add ress issue s within p aper claim s when sit es use the pay to pr ovider loo p. The add ress infor mation con tained in this loop cannot be directly m apped to t he paper c laim form. FSC moves the pay t o provider address t o the bill ing addres s fields s o that the y will app ear on the paper cla im form. | |
| 10985 | User Param eters | |
| 10986 | Preprocess or control page: C onfigure D efault Bil ling Provi der | |
| 10987 | This page is also us ed to chan ge payer I Ds for non -primary c laims. See 3.1. | |
| 10988 | Field Name | |
| 10989 | VistA 432 | |
| 10990 | X12 Locati on | |
| 10991 | Value | |
| 10992 | Primary ID | |
| 10993 | CI5 – 3 | |
| 10994 | 2010BB NM1 09 | |
| 10995 | HCCH payer ID | |
| 10996 | Claim Type | |
| 10997 | N/A | |
| 10998 | N/A | |
| 10999 | I – Instit utional | |
| 11000 | P – Profes sional | |
| 11001 | Functional Requireme nts | |
| 11002 | F REQ-1: M ove the pa y-to addre ss informa tion in th e billing provider l oop | |
| 11003 | Determine if the fol lowing sta tements ar e true for all claim s: | |
| 11004 | The pay to provider address (R ecord PRV1 – 7 / 201 0AB N301) is not nul l | |
| 11005 | The payer ID (CI5 – 3/ 2010BB NM109) is in the tab le | |
| 11006 | If both st atements a re true, t hen do the following : | |
| 11007 | Copy the p ay to prov ider addre ss line on e (Record PRV1 – 7 / 2010AB N3 01) to bil ling provi der addres s line one (Record P RV – 4 / 2 010AA N301 ) | |
| 11008 | Copy the p ay to prov ider addre ss line tw o (Record PRV1 – 8 / 2010AB N3 02) to bil ling provi der addres s line two (Record P RV – 11 / 2010AA N30 1) | |
| 11009 | Copy the p ay to prov ider city (Record PR V1 – 9 / 2 010AB N401 ) to billi ng provide r city (Re cord PRV – 5 / 2010A A N401) | |
| 11010 | Copy the p ay to prov ider state (Record P RV1 – 10 / 2010AB N4 02) to bil ling provi der state (Record PR V – 6 / 20 10AA N402) | |
| 11011 | Copy the p ay to prov ider zip ( Record PRV 1 – 11 / 2 010AB N403 ) to billi ng provide r zip (Rec ord PRV – 7 / 2010AA N403) | |
| 11012 | Modify sec ondary IDs for Medic are Claims | |
| 11013 | Program Na me: Modif ySecondary IDsMedicar e.exe | |
| 11014 | Overview | |
| 11015 | This prepr ocessor re moves vali d 5010 pro vider IDs that are n ot allowed by Medica re. If the provider ID type is not valid for 5010 it is remo ved within the map. | |
| 11016 | Business C ase | |
| 11017 | Medicare h as limited the secon dary IDs t hat the VA may use | |
| 11018 | User Param eters – N/ A | |
| 11019 | Functional Requireme nts | |
| 11020 | F REQ-1: R emove seco ndary IDs and qualif iers on Me dicare Par t A claims | |
| 11021 | If the des tination p ayer ID (C I5 – 3 / 2 010BB NM10 9) is 12M6 1 (Medicar e Part A) then: | |
| 11022 | Remove 231 0A attendi ng provide r secondar y ID if qu alifier is not 1G | |
| 11023 | If OPR2 - 2 is not 1 G remove - 2 and 3 | |
| 11024 | If OPR2 - 4 is not 1 G remove - 4 and 5 | |
| 11025 | If OPR2 - 6 is not 1 G remove - 6 and 7 | |
| 11026 | If OPR2 - 8 is not 1 G remove - 8 and 9 | |
| 11027 | Remove 231 0B operati ng provide r secondar y ID if qu alifier is not 1G | |
| 11028 | If OPR3 - 2 is not 1 G remove - 2 and 3 | |
| 11029 | If OPR3 - 4 is not 1 G remove - 4 and 5 | |
| 11030 | If OPR3 - 6 is not 1 G remove - 6 and 7 | |
| 11031 | If OPR3 - 8 is not 1 G remove - 8 and 9 | |
| 11032 | Remove 231 0C other o perating p rovider se condary ID if qualif ier is not 1G | |
| 11033 | If OPR4 - 2 is not 1 G remove - 2 and 3 | |
| 11034 | If OPR4 - 4 is not 1 G remove - 4 and 5 | |
| 11035 | If OPR4 - 6 is not 1 G remove - 6 and 7 | |
| 11036 | If OPR4 - 8 is not 1 G remove - 8 and 9 | |
| 11037 | Remove 231 0D renderi ng provide r secondar y ID if qu alifier is not 1G | |
| 11038 | If OPRA - 2 is not 1 G remove - 2 and 3 | |
| 11039 | If OPRA - 4 is not 1 G remove - 4 and 5 | |
| 11040 | If OPRA - 6 is not 1 G remove - 6 and 7 | |
| 11041 | If OPRA - 8 is not 1 G remove - 8 and 9 | |
| 11042 | Remove 231 0F referri ng provide r secondar y ID if qu alifier is not 1G | |
| 11043 | If OPR5 - 2 is not 1 G remove - 2 and 3 | |
| 11044 | If OPR5 - 4 is not 1 G remove - 4 and 5 | |
| 11045 | If OPR5 - 6 is not 1 G remove - 6 and 7 | |
| 11046 | Remove 231 0E Service facility loop | |
| 11047 | Remove SUB 2 - 7, 8, 9, 10, 11, 12 | |
| 11048 | Remove 242 0A line op erating pr ovider sec ondary ID if qualifi er is not 1G | |
| 11049 | If LOPE - 10 is not 1G remove - 10 and 1 1 | |
| 11050 | If LOPE - 12 is not 1G remove - 12 and 1 3 | |
| 11051 | If LOPE - 14 is not 1G remove - 14 and 1 5 | |
| 11052 | Remove 242 0B line ot her operat ing provid er seconda ry ID if q ualifier i s not 1G | |
| 11053 | If LOP1 - 10 is not 1G remove - 10 and 1 1 | |
| 11054 | If LOP1 - 12 is not 1G remove - 12 and 1 3 | |
| 11055 | If LOP1 - 14 is not 1G remove - 14 and 1 5 | |
| 11056 | Remove 242 0C line re ndering pr ovider sec ondary ID if qualifi er is not 1G | |
| 11057 | If LREN - 10 is not 1G remove - 10 and 1 1 | |
| 11058 | If LREN - 12 is not 1G remove - 12 and 1 3 | |
| 11059 | If LREN - 14 is not 1G remove - 14 and 1 5 | |
| 11060 | Remove 242 0D line re ferring pr ovider sec ondary ID if qualifi er is not 1G | |
| 11061 | If LREF - 10 is not 1G remove - 10 and 1 1 | |
| 11062 | If LREF - 12 is not 1G remove - 12 and 1 3 | |
| 11063 | If LREF - 14 is not 1G remove - 14 and 1 5 | |
| 11064 | F REQ-2: M odify or r emove seco ndary IDs and qualif iers on Me dicare Par t B claims | |
| 11065 | If the des tination p ayer ID (C I5 – 3 / 2 010BB NM10 9) is equa l to SMTX1 (Medicare Part B) t hen: | |
| 11066 | Change qua lifier for location code in 20 10AA from 1C to G2 | |
| 11067 | If CI1A – 6 is equal to 1C cha nge it to G2 | |
| 11068 | Remove 231 0A referri ng provide r secondar y ID if qu alifier is not 1G or 0B | |
| 11069 | OPR5 - 2 i s not 1G o r 0B remov e - 2 and 3 | |
| 11070 | OPR5 - 4 i s not 1G o r 0B remov e - 4 and 5 | |
| 11071 | OPR5 - 6 i s not 1G o r 0B remov e - 6 and 7 | |
| 11072 | Change 231 0B renderi ng provide r qualifie r to G2 | |
| 11073 | If OPRA - 2 is 1C ch ange to G2 | |
| 11074 | If OPRA - 4 is 1C ch ange to G2 | |
| 11075 | If OPRA - 6 is 1C ch ange to G2 | |
| 11076 | If OPRA - 8 is 1C ch ange to G2 | |
| 11077 | Remove all 2310C Ser vice facil ity second ary IDs | |
| 11078 | Remove SUB 2 - 7, 8, 9, 10, 11, 12 | |
| 11079 | Change 231 0D supervi sing provi der qualif ier to G2 | |
| 11080 | If OPR8 - 2 is EI ch ange to G2 | |
| 11081 | If OPR8 - 4 is EI ch ange to G2 | |
| 11082 | If OPR8 - 6 is EI ch ange to G2 | |
| 11083 | If OPR8 - 8 is EI ch ange to G2 | |
| 11084 | Remove 242 0B Purchas e Service secondary ID if qual ifier is n ot 1G | |
| 11085 | If LPUR - 6 is not 1G remove LPUR - 6 a nd 7 | |
| 11086 | Remove 242 0D line su pervising provider s econdary I D if quali fier is G2 | |
| 11087 | LSUP - 10 is G2 remo ve - 10 an d 11 | |
| 11088 | LSUP - 12 is G2 remo ve - 12 an d 13 | |
| 11089 | LSUP - 14 is G2 remo ve - 14 an d 15 | |
| 11090 | Remove 242 0F line re ferring pr ovider sec ondary ID if qualifi er is not 1G | |
| 11091 | LREF - 10 is not 1G remove - 1 0 and 11 | |
| 11092 | LREF - 12 is not 1G remove - 1 2 and 13 | |
| 11093 | LREF - 14 is not 1G remove - 1 4 and 15 | |
| 11094 | Remove Oth er Payer I nformation from Clai m | |
| 11095 | Program Na me: Remov eOtherPaye rProviderI nfromation .exe | |
| 11096 | Overview | |
| 11097 | This progr am removes all other payer pro vider info rmation fr om a claim . | |
| 11098 | Business C ase | |
| 11099 | According to the 501 0 guide th e other pa yer provid er informa tion is no t required after the implement ation of N PI. VA has given the sites the ability t o submit t his inform ation if t he payer r equires it . The VA h as learned that Medi care will reject cla ims submit ted with t his inform ation. To reduce the risk of r ejects fro m Medicare and payer s that ado pt Medicar e edits FS C implemen ted this c hange to f ilter out the data e ven if sub mitted by the site u nless the payer has requested the inform ation be s ent. | |
| 11100 | User Param eters | |
| 11101 | Preprocess or control page: C onfigure R emove othe r payer in formation | |
| 11102 | Field name | |
| 11103 | VistA 432 | |
| 11104 | X12 locati on | |
| 11105 | Value | |
| 11106 | Primary ID | |
| 11107 | CI5 – 3 | |
| 11108 | 2010BB NM1 09 | |
| 11109 | HCCH payer ID | |
| 11110 | Functional Requireme nts | |
| 11111 | F REQ-1: R emove othe r payer pr ovider inf ormation f rom claims | |
| 11112 | If the des tination p ayer ID (C I5 – 3 / 2 010BB NM10 9) is in c ontrol tab le then re move the f ollowing r ecords and all assoc iated fiel ds: | |
| 11113 | OP1 - Othe r payer re ndering pr ovider (83 7I 2330G 8 37P 2330D) | |
| 11114 | OP1A - Oth er payer a ttending p hysician d ata (837I 2330C) | |
| 11115 | OP2 - Othe r payer op erating ph ysician da ta (837I 2 330D) | |
| 11116 | OP3 - Othe r payer se rvice faci lity data (837I 2330 F) | |
| 11117 | OP4 - Othe r payer re ferring pr ovider dat a (837P 23 30C; 837I 2330H) | |
| 11118 | OP7 - Othe r payer se rvice faci lity data (837P 2330 E) | |
| 11119 | OP8 - Othe r payer su pervising provider d ata (837P 2330F) | |
| 11120 | OP9 - Othe r payer ot her operat ing provid er data (8 37I 2330E) | |
| 11121 | Remove Sec ondary IDs from Clai ms | |
| 11122 | Program Na me: Remov eSecondary IDsFromCla ims.exe | |
| 11123 | Overview | |
| 11124 | This prepr ocessor re moves all secondary provider I D numbers from a cla im with th e exceptio n of the b illing pro vider tax ID and the HCCH site ID unless the payer is author ized to re ceive addi tional pay er IDs | |
| 11125 | Business C ase | |
| 11126 | The 5010 s tandard do es require secondary IDs to be submitted if a NPI is on the claim. At the time o f implemen tation it was not kn own if pay ers would fully conv ert their systems to NPI. This process a llows the data to co ntinue to be submitt ed. | |
| 11127 | User Param eters | |
| 11128 | Preprocess or control page: C onfigure R emove Seco ndary ID f rom Claims | |
| 11129 | Field Name | |
| 11130 | VistA 432 | |
| 11131 | X12 Locati on | |
| 11132 | Value | |
| 11133 | Primary ID | |
| 11134 | CI5 – 3 | |
| 11135 | 2010BB NM1 09 | |
| 11136 | HCCH payer ID | |
| 11137 | Functional Requireme nts | |
| 11138 | F REQ-1: R emove seco ndary prov ider IDs f rom claims | |
| 11139 | If the des tination p ayer ID (C I5 – 3 / 2 010BB NM10 9) is in c ontrol tab le, then r emove data from the following records an d fields: | |
| 11140 | CI1A - 6, 7, 8, 9 Bi lling prov ider secon dary IDs ( 837P 2010A A) | |
| 11141 | SUB2 - 7, 8, 9, 10, 11, 12 Lab facility secondary IDs (837P 2310C; 837 I 2310C) | |
| 11142 | OPR2 all A ttending p rovider se condary ID s (837I 23 10A) | |
| 11143 | OPR3 all O perating p rovider se condary ID s (837I 23 30B) | |
| 11144 | OPR4 all O ther opera ting provi der second ary IDs (8 37I 2330C) | |
| 11145 | OPR5 all R eferring p rovider se condary ID s (837P 23 10A; 837I 2310F) | |
| 11146 | OPR8 all S upervising provider secondary IDs (837P 2310D) | |
| 11147 | OPRA all R endering p rovider se condary ID s (837I 23 10D; 837P 2310B) | |
| 11148 | LOPE - 10, 11. 12, 1 3, 14 and 15 Line le vel operat ing physic ian second ary IDs (8 37I 2420A) | |
| 11149 | LOP1 - 10, 11. 12, 1 3, 14 and 15 Line le vel other operating physician secondary IDs (837I 2420B) | |
| 11150 | LREN - 10, 11. 12, 1 3, 14 and 15 Line le vel render ing provid er seconda ry IDs (83 7I 2420C; 837P 2420A ) | |
| 11151 | LPUR - 6 a nd 7 Line level purc hase servi ce provide r secondar y IDs (837 P 2420B) | |
| 11152 | LSUP - 10, 11. 12, 1 3, 14 and 15 Line le vel superv ising prov ider secon dary IDs ( 837P 2420D ) | |
| 11153 | LREF - 10, 11. 12, 1 3, 14 and 15 Line le vel referr ing provid er seconda ry IDs (83 7I 2420D; 837P 2420F ) | |
| 11154 | Compare Su bscriber a nd Patient | |
| 11155 | Program Na me: Compa reSubscrib erData.exe | |
| 11156 | Overview | |
| 11157 | The 5010 X 12 standar d only all ows the pa tient loop (2010CA) to be subm itted if t he patient and subsc riber shar e a common insurance member ID number. F SC enforce s this rul e by overw riting the subscribe r informat ion with t he patient informati on if, on the inboun d claim, t he patient member ID number (P T3 - 3) is not equal to the su bscriber m ember ID ( CI6 - 3). FSC will n ot enforce this rule on the pa yers liste d in the u ser-define d table. | |
| 11158 | Business C ase | |
| 11159 | It is unkn own at the time of i mplementat ion whethe r payers w ill be abl e to proce ss claims without th e patient loop. | |
| 11160 | User Param eters | |
| 11161 | Preprocess or control page: C onfigure P ayers to C ompare Sub scriber | |
| 11162 | Field Name | |
| 11163 | VistA 432 | |
| 11164 | X12 Locati on | |
| 11165 | Value | |
| 11166 | Primary ID | |
| 11167 | CI5 – 3 | |
| 11168 | 2010BB NM1 09 | |
| 11169 | HCCH payer ID | |
| 11170 | Functional Requireme nts | |
| 11171 | F REQ-1: M ove patien t informat ion into s ubscriber loop | |
| 11172 | If the des tination p ayer ID (C I5 – 3 / 2 010BB NM10 9) is not in control table the n determin e if the f ollowing s tatement i s true: | |
| 11173 | Is the pat ient prima ry ID (PT3 - 3 / No 5010 X12 f ield) not equal to t he subscri ber primar y ID (CI6 – 3 / 2010 BA NM109)? | |
| 11174 | If the sta tement is true, then perform t he followi ng steps: | |
| 11175 | Set patien t relation ship to in sured (PT2 – 3 / 200 0B SBR08) equal to 1 8 | |
| 11176 | Set subscr iber last name (CI2 – 3 / 2010 BA NM103) equal to p atient las t name (PT 1 – 4 / 20 10CA NM103 ) | |
| 11177 | Delete dat a element patient la st name (P T1 – 4 / 2 010CA NM10 3) | |
| 11178 | Set subscr iber first name (CI2 – 4 / 201 0BA NM104) equal to patient fi rst name ( PT1 – 5 / 2010CA NM1 04) | |
| 11179 | Delete dat a element patient fi rst name ( PT1 – 5 / 2010CA NM1 04) | |
| 11180 | Set subscr iber middl e name (CI 2 – 5 / 20 10BA NM105 ) equal to patient m iddle name (PT1 – 6 / 2010CA N M105) | |
| 11181 | Delete dat a element patient mi ddle name (PT1 – 6 / 2010CA NM 105) | |
| 11182 | Set subscr iber addre ss (CI2 – 7 / 2010BA N301) equ al to pati ent addres s (PT1 – 7 / 2010CA N301) | |
| 11183 | Delete dat a element patient ad dress (PT1 – 7 / 201 0CA N301) | |
| 11184 | Set subscr iber city (CI2 – 8 / 2010BA N4 01) equal to patient city (PT1 – 9 / 201 0CA N401) | |
| 11185 | Delete dat a element patient ci ty (PT1 – 9 / 2010CA N401) | |
| 11186 | Set subscr iber state (CI2 – 9 / 2010BA N 402) equal to patien t state (P T1 – 10 / 2010CA N40 2) | |
| 11187 | Delete dat a element patient st ate (PT1 – 10 / 2010 CA N402) | |
| 11188 | Set subscr iber zip c ode (CI2 – 10 / 2010 N403) equ al to pati ent zip (P T1 – 11 / 2010CA N40 3) | |
| 11189 | Delete dat a element patient zi p (PT1 – 1 1 / 2010CA N403) | |
| 11190 | Set subscr iber birth date (CI2 – 11 / 20 10BA DMG02 ) equal to patient b irth date (PT1 – 12 / 2010CA D MG02) | |
| 11191 | Delete dat a element patient bi rth date ( PT1 – 12 / 2010CA DM G02) | |
| 11192 | Set subscr iber gende r code (CI 2 – 12 / 2 010BA DMG0 3) equal t o patient gender cod e (PT1 – 1 3 / 2010CA DMG03) | |
| 11193 | Delete dat a element patient ge nder code (PT1 – 13 / 2010CA D MG03) | |
| 11194 | Set subscr iber telep hone numbe r (CI2 – 1 3 / 2010BA PER04) eq ual to pat ient telep hone numbe r (PT2 – 3 / 2010CA PER04) | |
| 11195 | Delete dat a element patient te lephone nu mber (PT2 – 3 / 2010 CA PER04) | |
| 11196 | Set subscr iber addre ss line 2 (CI2 – 14 / 2010BA N 302) equal to patien t address line 2 (PT 1 – 8 / 20 10CA N302) | |
| 11197 | Delete dat a element patient ad dress line 2 (PT1 – 8 / 2010CA N302) | |
| 11198 | Set subscr iber name suffix (CI 2 – 15 / 2 010BA NM10 7) equal t o patient name suffi x (PT1 – 2 0 / 2010CA NM107) | |
| 11199 | Delete pat ient name suffix (PT 1 – 20 / 2 010CA NM10 7) | |
| 11200 | Set subscr iber prima ry ID qual ifier (CI6 - 2, 2010 BA NM108) equal to p atient pri mary ID qu alifier (P T3 – 2 / 2 010CA NM10 8) | |
| 11201 | Delete pat ient prima ry ID qual ifier (PT3 - 2, 2010 CA NM108) | |
| 11202 | Set subscr iber prima ry ID (CI6 - 3, 2010 BA NM109) equal to p atient pri mary ID (P T3 – 3 / 2 010CA NM10 9) | |
| 11203 | Delete sub scriber SS N qualifie r (CI6 - 4 ) | |
| 11204 | Delete sub scriber SS N (CI6 - 5 ) | |
| 11205 | Swap Addre ss Lines | |
| 11206 | Program Na me: SwapA ddress.exe | |
| 11207 | Overview | |
| 11208 | If VistA s ubmits a c laim where the desti nation pay er is AARP , this pro gram switc hes addres s lines on e and two within the billing p rovider an d pay to p rovider lo op. | |
| 11209 | Business C ase | |
| 11210 | This prepr ocess was created to resolve a payer-spe cific requ irement. | |
| 11211 | User Param eters – N/ A | |
| 11212 | Functional Requireme nts | |
| 11213 | F REQ-1: S wap billin g address lines one and two fo r AARP cla ims | |
| 11214 | If the des tination p ayer ID (C I5 – 3 / 2 010AA NM10 9) is equa l to 36273 and the b illing add ress line two (PRV - 11 / 2010 AA N302) i s not null , then: | |
| 11215 | Move billi ng address line one (PRV – 4 / 2010AA N3 01) to bil ling addre ss line tw o (PRV – 1 1 / 2010AA N302) | |
| 11216 | Move billi ng address line two (PRV – 11 / 2010AA N 302) to bi lling addr ess line o ne (PRV – 3 / 2010AA N302) | |
| 11217 | F REQ-2: S wap pay to address o ne and two for AARP claims | |
| 11218 | If the des tination p ayer ID (C I5 – 3 / 2 010AA NM10 9) is equa l to 36273 and the p ay to addr ess line t wo (PRV1 - 8 / 2010A B N302) is not null, then: | |
| 11219 | Move pay t o address line one ( PRV1 – 7 / 2010AB N3 01) to pay to addres s line two (PRV1 – 8 / 2010AB N302) | |
| 11220 | Move pay t o address line two ( PRV1 – 8 / 2010AB N3 02) to pay to addres s line one (PRV1 – 7 / 2010AB N302) | |
| 11221 | Appendix C – FSC Def ault Value s | |
| 11222 | Field Name | |
| 11223 | Institutio nal Locati on | |
| 11224 | Profession al Locatio n | |
| 11225 | Value | |
| 11226 | Informatio n source | |
| 11227 | BHT01 | |
| 11228 | BHT01 | |
| 11229 | 0019 | |
| 11230 | Original t ransaction | |
| 11231 | BHT02 | |
| 11232 | BHT02 | |
| 11233 | 00 | |
| 11234 | Transactio n type | |
| 11235 | BHT06 | |
| 11236 | BHT06 | |
| 11237 | CH | |
| 11238 | Submitter name quali fier | |
| 11239 | NM101 | |
| 11240 | NM101 | |
| 11241 | 41 | |
| 11242 | Submitter name type | |
| 11243 | NM102 | |
| 11244 | NM102 | |
| 11245 | 2 | |
| 11246 | Submitter name | |
| 11247 | NM103 | |
| 11248 | NM103 | |
| 11249 | DEPT VETER ANS AFFAIR S | |
| 11250 | Submitter ID qualifi er | |
| 11251 | NM108 | |
| 11252 | NM108 | |
| 11253 | 46 | |
| 11254 | Submitter ID | |
| 11255 | NM109 | |
| 11256 | NM109 | |
| 11257 | 741612229 | |
| 11258 | Submitter contact qu alifier | |
| 11259 | PER01 | |
| 11260 | PER01 | |
| 11261 | IC | |
| 11262 | Submitter contact na me | |
| 11263 | PER02 | |
| 11264 | PER02 | |
| 11265 | ATTN EDI T EAM | |
| 11266 | Submitter contact nu mber quali fier | |
| 11267 | PER03 | |
| 11268 | PER03 | |
| 11269 | TE | |
| 11270 | Submitter phone numb er | |
| 11271 | PER04 | |
| 11272 | PER04 | |
| 11273 | 5124605678 | |
| 11274 | Receiver n ame qualif ier | |
| 11275 | NM101 | |
| 11276 | NM101 | |
| 11277 | 40 | |
| 11278 | Receiver n ame type | |
| 11279 | NM102 | |
| 11280 | NM102 | |
| 11281 | 2 | |
| 11282 | Receiver n ame | |
| 11283 | NM103 | |
| 11284 | NM103 | |
| 11285 | For 837-I WEBMD | |
| 11286 | For 837-P EMDEON | |
| 11287 | Receiver I D qualifie r | |
| 11288 | NM108 | |
| 11289 | NM108 | |
| 11290 | 46 | |
| 11291 | Receiver I D | |
| 11292 | NM109 | |
| 11293 | NM109 | |
| 11294 | 133052274 |
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