7. hipaa transactions and code sets compliant form data.pdf · the arrow - – is used to indicate...

7. HIPAA Transactions and Code Sets Compliant Form

8. 837I and 837P Data Segments

The following pages contain some of the medical coding data segments from eachtransaction standard as published in the HIPAA Implementation Guide at: www.wpc-edi.com/hipaa/HIPAA_40.asp .

The arrow - – is used to indicate the specific transaction segment excerptthat is displayed in detail in this Guidebook.

Below are the definitions for the “USAGE” text that appears in this chapter

Industry Usages:

Required This item must be used to be compliant with this implementationguide.

Not Used This item should not be used when complying with thisimplementation guide.

Situational The use of this item varies, depending on data content and businesscontext. The defining rule is generally documented in a syntax or usage note attached tothe item.* The item should be used whenever the situation defined in the note is true;otherwise, the item should not be used.

* NOTEIf no rule appears in the notes, the item should be sent if the datais available to the sender.

POS.# - Position NumberSEG.ID - Segment IdentifierREF.DES. - Reference Description

New Note Added

Note

New Note Added

EDI Transmission Example837 Institutional ClaimAssumptionsPatient is the same person as the Subscriber. The Primary Payer is Medicareand the Secondary payer is State Teachers. The bill is a 141 Type of Bill.

Primary Payer Subscriber: John T DoeSubscriber Address: 125 City Avenue, Centerville, PA 17111Sex: MDOB: 11/11/1926Medicare Insurance ID#: 030005074APayer ID #: 00435

Patient: Same as Primary Subscriber

Destination Payer: Medicare B

Submitter: Jones HospitalEDI #: 12345

Receiver: MedicareEDI #: 00120

Billing Provider: Jones HospitalMedicare Provider #330127Address: 225 Main Street Barkley BuildingCenterville, PA 17111

Attending Physician: John J JonesUPIN # B99937

Patient Account Number: 756048QDate of Admission: 09/11/96Statement Period Date: 09/11/96 - 09/11/96Place of Service: Inpatient HospitalOccurrence Codes and Dates:A1 11/11/26A2 11/01/91B1 11/11/26B2 01/01/87Condition Codes:09Value Codes:

A2 $15.31ICD-9 Procedure Codes and Dates:15.3 09/11/96Principal Diagnosis Code:366.9Secondary Diagnosis Codes:

401.9794.31Number of Covered Days: 1

Services:Institutional Services Rendered:Revenue Code: 305 HCPCS Procedure Code: 85025 Unit: 1 Price$13.39Revenue Code: 730 HCPCS Procedure Code: 93005 Unit: 1 Price:$76.54Total Charges: $89.93

Secondary Payer Subscriber: Jane S Doe (wife)Subscriber Address: 125 City Avenue, Centerville, PA 17111Sex: MDOB: 11/11/1926State Teachers ID#: 222004433Payer ID #: 1135

Transmission:Complete Data String:ST*837*987654~BHT*0019*00*0123*19960918*0932*CH~REF*87*004010X096~NM1*40*2*MEDICARE*****46*00120~PER*IC*JANE DOE*TE*9005555555~NM1*41*2*JONES HOSPITAL*****46*12345~HL*1**20*1~PRV*BI*ZZ*203BA0200N~NM1*85*2*JONES HOSPITAL*****XX*330127~PRV*AT*ZZ*363LP0200N~N3*225 MAIN STREET BARKLEY BUILDING~N4*CENTERVILLE*PA*17111~REF*G2*987654080~HL*2*1*22*0~SBR*P*18*******MB~NM1*IL*1*DOE*JOHN*T***MI*030005074A~N3*125 CITY AVENUE~N4*CENTERVILLE*PA*17111~DMG*D8*19261111*M~NM1*PR*2*MEDICARE B*****PI*00435~

CLM*756048Q*89.93***14:A:1**Y*Y*Y~DTP*434*D8*19960911~CL1*3*1~HI*BK:366.9~HI*BF:401.9*BF:794.31~HI*BQ:15.3:D8:19960911~HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~HI*BE:A2:::15.31~HI*BG:09~

NM1*71*1*JONES*JOHN*J***XX*B99937~PRV*AT*ZZ*363LP0200N~SBR*S*01*351630*STATE TEACHERS*GP****CI~DMG***F~OI***Y***Y~NM1*IL*1*DOE*JANE*S***MI*222004433~N3*125 CITY AVENUE~N4*CENTERVILLE*PA*17111~NM1*PR*2*STATE TEACHERS*****PI*1135~LX*1~SV2*305*HC:85025*13.39*UN*1~DTP*472*D8*19960911~LX*2~SV2*730*HC:93005*76.54*UN*3~DTP*472*D8*19960911~SE*44*987654~

837 Health Care Claim: Professional

1. The 837 transaction is designed to transmit one or more claims for each billing provider. The hierarchy ofthe looping structure is billing provider, subscriber, patient, claim level, and claim service line level. Billingproviders who sort claims using this hierarchy will use the 837 more efficiently because information that appliesto all lower levels in the hierarchy will not have to be repeated within the transaction.2. This standard is also recommended for the submission of similar data within a pre-paid managed carecontext. Referred to as capitated encounters, this data usually does not result in a payment, though it ispossible to submit a “mixed” claim that includes both pre-paid and request for payment services. This standardwill allow for the submission of data from providers of health care products and services to a Managed CareOrganization or other payer. This standard may also be used by payers to share data with plan sponsors,employers, regulatory entities and Community Health Information Networks.3. This standard can, also, be used as a transaction set in support of the coordination of benefits claimsprocess. Additional looped segments can be used within both the claim and service line levels to transfer eachpayer’s adjudication information to subsequent payers.

New Note Added

New Note Added

Codes N1, N2, and N4

EDI Transmission Example837 – Professional Claim

AssumptionsPatient is the same person as the Subscriber. Payer is an HMO. Encounter istransmitted through a clearinghouse. Submitter is the billing service, receiveris a repricer.

SUBSCRIBER/PATIENT: Ted Smith,ADDRESS:236 N. Main St., Miami, Fl, 33413,TELEPHONE NUMBER: 305-555-1111SEX: MDOB: 05/01/43EMPLOYER: ACME Inc.GROUP #: 12312-APAYER ID NUMBER: SSNSSN: 000-22-1111

DESTINATION PAYER: Alliance Health and Life Insurance Company(AHLIC),PAYOR ADDRESS: 2345 West Grand Blvd, Detroit, MI 48202. ,AHLIC #: 741234

RECEIVER: XYZ REPRICEREDI #: 66783JJT

BILLING PROVIDER/SENDER: Premier Billing Service,ADDRESS: 234 Seaway St, Miami, FL, 33111TIN: 587654321,EDI #: TGJ23CONTACT PERSON AND PHONE NUMBER: JERRY, 305-555-2222 ext.231

PAY-TO PROVIDER: Kildare Associates,PROVIDER ADDRESS: 2345 Ocean Blvd, Miami, Fl 33111.PROVIDER ID: 99878-ABATIN: 581234567

RENDERING PROVIDER: Dr. Ben Kildare/Family PractitionerAHLIC PROVIDER ID#: 9741234

PATIENT ACCOUNT NUMBER: 2-646-2967CASE:Patient has sore throat.DOS=10/03/98. POS=Office, TOS=06 (office visit)/08 (lab)

SERVICES RENDERED: Office visit, intermediate service, establishedpatient, throat culture.

FOLLOW-UP VISIT: DOS=10/10/97 because antibiotics didn’t work (paincontinues).SERVICES: Office visit, intermediate service, established patient, monoscreening.CHARGES: Office first visit = $40.00, Lab test for strep = $15.00, lab test formono = $10.00, Follow-up visit = $35.00. Total charges - $100.00.

ELECTRONIC ROUTE: billing provider(sender) to Clearinghouse to XYWREPRICER (receiver) to AHLIC (not shown);

Clearinghouse claim identification number = 17312345600006351.

Transmission

LOOPSEG # SEGMENT/ELEMENT STRING

1 HEADERST TRANSACTION SET HEADERST*837*0021~

2 BHT BEGINNING OF HIERARCHICAL TRANSACTIONBHT*0019*00*0123*19981015*1023*RP~

3 REF TRANSMISSION TYPE IDENTIFICATIONREF*87*004010X098~

4 1000A SUBMITTERNM1 SUBMITTERNM1*41*2*PREMIER BILLINGSERVICE*****46*TGJ23~

5 PER SUBMITTER EDI CONTACT INFORMATIONPER*IC*JERRY*TE*3055552222*EX*231~

6 1000B RECEIVERNM1 RECEIVER NAMENM1*40*2*REPRICER XYZ*****46*66783JJT~


7 2000A BILLING/PAY-TO PROVIDER HL LOOPHL-BILLING PROVIDERHL*1**20*1~

8 2010AA BILLING PROVIDERNM1 BILLING PROVIDER NAMENM1*85*2*PREMIER BILLINGSERVICE*****MI*587654321~

9 N3 BILLING PROVIDER ADDRESSN3*234 Seaway St~

10 N4 BILLING PROVIDER LOCATIONN4*Miami*FL*33111~

11 2010AB PAY-TO PROVIDERNM1 PAY-TO PROVIDER NAMENM1*87*2*KILDARE ASSOC*****24*581234567~

12 N3 PAY-TO PROVIDER ADDRESSN3*2345 OCEAN BLVD~

13 N4 PAY-TO PROVIDER CITYN4*MIAMI*FL*33111~

14 2000B SUBSCRIBER HL LOOPHL-SUBSCRIBERHL*2*1*22*0~

15 SBR SUBSCRIBER INFORMATIONSBR*P*18*12312-A******HM~

16 2010BA SUBSCRIBERNM1 SUBSCRIBER NAMENM1*IL*1*SMITH*TED****34*000221111~

17 N3 SUBSCRIBER ADDRESSN3*236 N MAIN ST~

18 N4 SUBSCRIBER CITYN4*MIAMI*FL*33413~

19 DMG SUBSCRIBER DEMOGRAPHIC INFORMATIONDMG*D8*19430501*M~


20 2010BB SUBSCRIBER/PAYERNM1 PAYER NAMENM1*PR*2*ALLIANCE HEALTH AND LIFE INSURANCE*****PI*741234~

21 N2 PAYER ADDITIONAL NAME INFORMATIONN2*COMPANY~

22 2300 CLAIMCLM CLAIM LEVEL INFORMATIONCLM*26462967*100***11::1*Y*A*Y*Y*C~

23 DTP DATE OF ONSETDTP*431*D8*19981003~

24 REF CLEARING HOUSE CLAIM NUMBER (Added byC.H.)REF*D9*17312345600006351~

25 HI HEALTH CARE DIAGNOSIS CODESHI*BK:0340*BF:V7389~

26 2310B RENDERING PROVIDERNM1 RENDERING PROVIDER NAMENM1*82*1*KILDARE*BEN***34*112233334~

27 PRV RENDERING PROVIDER INFORMATIONPRV*PE*ZZ*203BF0100Y~

28 2310D SERVICE LOCATIONNM1 SERVICE FACILITY LOCATIONNM1*77*2*KILDAREASSOCIATES*****24*581234567~

29 N3 SERVICE FACILITY ADDRESSN3*2345 OCEAN BLVD~

30 N4 SERVICE FACILITY CITY/STATE/ZIPN4*MIAMI*FL*33111~

31 2400 SERVICE LINELX SERVICE LINE COUNTERLX*1~

32 SV1 PROFESSIONAL SERVICESV1*HC:99213*40*UN*1***1**N~

LOOPSEG # SEGMENT/ELEMENT STRING33 DTP DATE - SERVICE DATE(S)

DTP*472*D8*19981003~




36 DTP DATE - SERVICE DATE(S)DTP*472*D8*19981003~







43 TRAILERSE TRANSACTION SET TRAILERSE*43*0021~

Complete data string:ST*837*0021~BHT*0019*00*0123*19981015*1023*RP~REF*87*004010X098~NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~PER*IC*JERRY*TE*3055552222*EX*231~NM1*40*2*REPRICER XYZ*****46*66783JJT~HL*1**20*1~NM1*85*2*PREMIER BILLING SERVICE*****24*587654321~N3*234 Seaway St~N4*Miami*FL*33111~NM1*87*2*KILDAREASSOC*****24*581234567~N3*2345 OCEAN BLVD~N4*MIAMI*FL*33111~HL*2*1*22*0~SBR*P*18*12312-A******HM~NM1*IL*1*SMITH*TED****34*000221111~N3*236 N MAIN ST~N4*MIAMI*FL*33413~DMG*D8*19430501*M~NM1*PR*2*ALLIANCE HEALTH AND LIFE INSURANCE *****PI*741234~

N2*COMPANY~CLM*26462967*100***11::1*Y*A*Y*Y*C~DTP*431*D8*19981003~REF*D9*17312345600006351~HI*BK:0340*BF:V7389~NM1*82*1*KILDARE*BEN****34*112233334~PRV*PE*ZZ*203BF0100Y~ NM1*77*2*KILDARE ASSOCIATES*****24*581234567~N3*2345 OCEAN BLVD~N4*MIAMI*FL*33111~LX*1~SV1*HC:99213*40*UN*1***1**N~DTP*472*D8*19981003~LX*2~SV1*HC:99214*15*UN*1***1**N~DTP*472*D8*19981003~LX*3~SV1*HC:87072*35*UN*1***2**N~DTP*472*D8*19981003~LX*4~SV1*HC:86663*10*UN*1***2**N~DTP*472*D8*19981010~SE*43*0021~

7. hipaa transactions and code sets compliant form data.pdf · the arrow - – is used to indicate...

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