LOOP

POSITION

SEGMENT ID

X-12

SEGMENT NAME

NOTES

 Located in Intellect Software

ISA

ISA

R

Interchange Control Header

Starts and identifies an interchange of zero or more functional groups and interchange-related control segments.

Automatically entered by Intellect

GS

R

Functional Group Header

Indicates the beginning of a functional group and provides control information

Automatically entered by Intellect

005

ST

R

Transaction Set Header

Start transaction set and assign a control number

Automatically entered by Intellect

010

BHT

R

Beginning Hierarchy Transaction

Indicates beginning of a transaction set

Automatically entered by Intellect

BHT01

R

Hierarchical Structure Code

Indicates the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
0019 - Information Source, Subscriber, Dependent

Automatically entered by Intellect

BHT02

R

Transaction Set Purpose Code

Identify purpose of the 837 transaction set
00 - Original: transmission which have never been sent to the receiver
18 - Reissue:  resending transmission that have been previously sent

Automatically entered by Intellect

BHT03

R

Reference Identification

Number assigned by the originator to identify the transaction within the originator's business application system.

Automatically entered by Intellect

BHT04

R

Date

Date of transaction creation

Automatically entered by Intellect

BHT05

R

Time

Time of transaction creation

Automatically entered by Intellect

BHT06

R

Transaction Type Code

Specifies the type of transaction:  claims or encounters
CH - Chargeable:  when transmission contains claims only
RP - Reporting:  when transmission contains encounters only

Automatically entered by Intellect

015

REF

R

Transmission Type Identification

Specifies identifying information

Automatically entered by Intellect

REF01

R

Reference Identification Qualifier

Code qualifying the Reference Identification
87 - Functional Category

Automatically entered by Intellect

REF02

R

Reference Identification

Reference information as defined for a particular Transaction Set or as specified by the Reference ID Qualifier:  
004010X098A1 for production Professional Claims

Automatically entered by Intellect

1000A

020

NM1

R

Submitter Name

To supply the full name of an individual or organizational entity

NM101

R

Entity Identifier Code

Code identifying an organizational entity, a physical location, property or an individual
41 - Submitter

Automatically entered by Intellect

NM102

R

Entity Type Qualifier

Code qualifying the type of entity (NM102 qualifies NM103)
1 - Person
2 - Non-Person Entity

Automatically entered by Intellect

NM103

R

Name Last or Organization Name

Submitter's last name or organizational name

Utility --►Set Up --► Clinic <Name>

NM108

R

Identification Code Qualifier

Code designating the system/method of code structure used for the identification code
46 - Electronic Transmitter ID Number (ETIN); established by a trading partner agreement

Automatically entered by Intellect

045

PER

R

Submitter EDI Contact Information

Contact person from submitter organization.

PER01

R

Contact Function Code

Code identifying the major duty or responsibility of the person or group named
IC - Information Contact

Automatically entered by Intellect

PER02

R

Name

Free-form name of contact

Utility --►Set Up --►Security --► Login Users <Operator Name>

PER03

R

Communication Number Qualifier

Code identifying the type of communication number
ED - EDI Access Number
EM - E-mail address
FX - Fax Number
TE - Telephone Number

Telephone Automatically entered by Intellect

PER04

R

Communication Number

Complete communications number including area code

Utility --►Set Up --► Clinic <Phone>

1000B

020

NM1

R

Receiver Name

NM101

R

Entity Identifier Code

Code identifying an organizational entity, a physical location, property or an individual
40 - Receiver

Automatically entered by Intellect

NM102

R

Entity Type Qualifier

Code qualifying the type of entity (NM102 qualifies NM103)
1 - Person
2 - Non-Person Entity

Automatically entered by Intellect

NM103

R

Name Last or Organization Name

Receiver's last name or organizational name

Utility --► Insurance <Name>  for the Billing --► Tele Com --► Submit <Insurance Code>

NM108

R

Identification Code Qualifier

Code designating the system/method of code structure used for the identification code
46 - Electronic Transmitter ID Number (ETIN); established by a trading partner agreement

Automatically entered by Intellect

NM109

R

Identification Code

Code identifying a party or other code

2000A

001

HL

R

Billing/Pay-To Provider Hierarchical Level

To identify dependencies among and the content of hierarchically related groups of data segments

HL01

R

Hierarchical ID Number

HL01 must begin with "1" and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.
1 - 1st HL segment

Automatically entered by Intellect

HL03

R

Hierarchical Level Code

Code defining the characteristic of a level in a hierarchical structure
20 - Information Source

Automatically entered by Intellect

HL04

R

Hierarchical Child Code

Indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
1 - additional subordinate HL data segment in this hierarchical structure

Automatically entered by Intellect

2010AA

015

NM1

R

Billing Provider Individual or Organization Name

Contains billing provider, pay-to provider information. Although the name of this loop/segment is “Billing Provider” the loop/segment really identifies the billing entity. The billing entity does not have to be a health care provider to use this loop. However, some payers do not accept claims from non-provider billing entities.

NM101

R

Entity Identifier Code

Code identifying an organizational entity, a physical location, property or an individual
85 - Billing Provider

NM102

R

Entity Type Qualifier

Code qualifying the type of entity (NM102 qualifies NM103)
1 - Person
2 - Non-Person Entity

NM103

R

Name Last or Organization Name

Billing Provider's last name or organization name

Utility --►Provider <Organization Name> from the code entered Charges --► Charge <Billing Prv>

NM108

R

Identification Code Qualifier

If code XX is used, then FTIN or SSN must be carried in the REF section. This should be the number used for 1099's.
24 - Employer's Identification  
34 - Social Security Number  
XX - Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used.

NM109

R

Billing Provider Identifier

Code identifying a party or other code (Your National Provider ID)

If your billing method is clinic (Utility --► Set Up --► Parameter <Billing Method> = C OR L with Utility --►Category <Billing (D/C/N)> = C) the following will be used Utility --► Insurance <Group NPI>. If your billing method is doctor (Utility --► Set Up --► Parameter <Billing Method> = D OR L with Utility --►Category <Billing (D/C/N)> = D) based on Intellect’s selection hierarchy one of the following will be used: Provider Facility: <Group NPI>. Provider Provider: <Group NPI>, or Provider: <Group NPI>.

025

N3

R

Address Information

Address

030

N4

R

Geographic Location

City, state, zip

N401

R

City

Biller's City

Utility --►Provider <City> from the code entered Charges --► Charge <Billing Prv>

N402

R

State

Biller's State

Utility --►Provider <State> from the code entered Charges --► Charge <Billing Prv>

N403

R

Zip Code

Biller's Zip Code

Utility --►Provider <Zip Code> from the code entered Charges --► Charge <Billing Prv>

035

REF

S

Billing Prov. Secondary ID

Required when a 2nd id is needed to identify Billing Provider. If XX is used in NM108/09, then FTIN or SSN must be used here

Automatically entered by Intellect

REF01

M

Reference Identification Qualifier

Code qualifying the Reference Identification. 1A Blue Cross Provider Number

REF02

M

Reference Identification

Billing Provider Secondary Identification Number

Utility --►Provider <Box 33 1> from the code entered Charges --► Charge <Billing Prv>

035

REF

S

Billing Prov. Secondary ID

Required when a 2nd id is needed to identify Billing Provider. If XX is used in NM108/09, then FTIN or SSN must be used here

REF01

R

Reference Identification Qualifier

Code qualifying the Reference Identification
BQ - HMO Code Number (Vendor # - Preferred Submission)
G2 - Provider Commercial # (Provider ID)
EI - Employer's Identification #
SY - Social Security Number

REF02

R

Reference Identification

Reference information as specified by the Reference ID Qualifier
Tax id

If your billing method is clinic (Utility --► Set Up --► Parameter <Billing Method> = C OR L with Utility --►Category <Billing (D/C/N)> = C) the following will be used Utility --► Set Up --► Clinic <IRS Number>. If your billing method is doctor (Utility --► Set Up --► Parameter <Billing Method> = D OR L with Utility --►Category <Billing (D/C/N)> = D) based on Intellect’s selection hierarchy one of the following will be used: Provider Facility: <Tax ID>. Provider Provider: <Tax ID>, or Provider: <IRS ID>.  If the Tax ID/IRS ID is null: Intellect sends the Utility --► Provider <Social Security No>. If sending the <Tax ID number>: EI qualifier is submitted.  If sending the <Social Security No> the SY qualifier is submitted.

2000B

001

HL

M

Subscriber Hierarchical Level

To identify dependencies among and the content of hierarchically related groups of data segments

HL01

R

Hierarchical ID Number

HL01 must begin with "1" and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.
2 - 2nd HL segment

Automatically entered by Intellect

HL02

R

Hierarchical Parent ID Number

HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Automatically entered by Intellect

HL03

R

Hierarchical Level Code

Code defining the characteristic of a level in a hierarchical structure
22 - Subscriber

Automatically entered by Intellect

HL04

R

Hierarchical Child Code

Indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
0 - when subscriber is patient;
1 - when patient is a dependent of subscriber

Registration --► Patient --► Insurance <Relationship to Insured>

005

SBR

O

Subscriber Information (SBR*P)

Contains current insurance carrier subscriber information

SBR01

R

Payor Responsibility Sequence Number Code

Identifies the insurance carrier's level of responsibility for a payment of a claim
P - Primary
S - Secondary
T - Tertiary or payer of last resort

Registration --► Patient --► Insurance <Primary/Secondary>

SBR02

S

Individual Relationship Code

Use this code only when the subscriber is the same person as the patient. If the subscriber is not the same person as the patient, leave blank.
18 -  self

Registration --► Patient --► Insurance <Relationship to Insured>

SBR03

S

Reference Identification

The subscriber's group number; not the subscriber #

If there is Insurance primary to Medicare, Registration --► Patient --► Insurance screen <Group No.> All other cases with secondary coverage the value entered on the patient’s Registration Patient insurance screen <Group No.>

SBR09

S

Claim Filing Indicator Code

Code identifying type of claim. Required prior to mandated used of PlanID. Not used after PlanID is mandated

Utility Insurance <Claim Filing Indicator> for Insurer being billed

2010BA

015

NM1

O

Subscriber's Name

Contains subscriber's name

NM101

R

Entity Identifier Code

IL - Insured or Subscriber

Automatically entered by Intellect

NM102

R

Entity Type Qualifier

1' = Person, '2' = Non-Person Entity

Automatically entered by Intellect for 1

NM103

R

Name Last or Organization Name

Subscriber last name or organization

If the patient is a dependent OR  you are submitting a secondary claim form AND other than self is the insured, then the name of the insured will come from the Registration --► Patient --►Insurance screen <Last Name> field.

NM104

S

Name First

Subscriber first name Enter into Insured Name field if Patient Relationship to Insured is not 'Self'

Registration --► Patient --►Insurance screen, <Insured First Name>, <Middle Initial> fields.

NM108

S

Identification Code Qualifier

MI' automatically entered by software

NM109

S

Identification Code

Subscriber Insured ID Number

Registration --►Patient --► Insurance screen <Subscriber No.> field.

025

N3

O

Address Information

Address

N301

R

Address 1

Subscriber's Address 1

If the patient is a dependent OR you are submitting a secondary claim form then the address of the insured will use the Registration --►Patient --► Insurance <Address> field.

030

N4

O

Geographic Location

City, state, zip

N401

R

City

Payer's City

Registration --►Patient --► Insurance  <City>

N402

R

State

Payer's State

Registration --►Patient --► Insurance <State>

N403

R

Zip Code

Payer's Zip Code

Registration --►Patient --► Insurance <Zip Code>

032

DMG

O

Subscriber's Demographic Information

Required when the Patient is the same as the Subscriber (Loop 2000B SBR02 - 18 (self))

DMG01

R

Date Time Period Format Qualifier

Indicating date format CCYYMMDD/ USES D8

Automatically entered by Intellect

DMG02

R

Date Time Period

Insured Date of Birth field if Patient Relationship to Insured is not 'Self'

Registration --► Patient <DOB>

DMG03

R

Gender Code

Insured Sex field if Patient Relationship to Insured is not 'Self'

Registration --► Patient <Sex (M/F/U)>

2010BB

015

NM1

O

Payer Name

Contains payer information

NM101

R

Entity Identifier Code

Code identifying an organizational entity, a physical location, property or an individual
PR - Payer

Automatically entered by Intellect

NM102

R

Entity Type Qualifier

Code qualifying the type of entity (NM102 qualifies NM103)
1 - Person
2 - Non-Person Entity

Automatically entered by Intellect

NM103

R

Name Last or Organization Name

Payer's last name or organization name

Utility --► Insurance <Name>

NM108

R

Identification Code Qualifier

Code designating the system/method of code structure used for the identification code. 'PI' is automatically entered by the software
PI - Payor ID

Automatically entered by Intellect

NM109

R

Identification Code

Payer ID

Utility --► Insurance <Payer Identifier>

025

N3

O

Address Information

Address

N301

R

Address 1

Payer's Address 1

Utility --► Insurance <Address>

030

N4

O

Geographic Location

City, state, zip

N401

R

City

Payer's City

Utility --► Insurance <City>

N402

R

State

Payer's State

Utility --► Insurance <State>

N403

R

Zip Code

Payer's Zip Code

Utility --► Insurance <Zip Code>

2300

130

CLM

R

Health Claim

Specifies basic data about claim header. Will follow loop 2010BC when subscriber is the patient.

CLM01

R

Claim Submitter's Identifier

Patient Control No. assigned by provider

Registration --►Regular --►Patient <Patient Account No>

CLM02

R

Monetary Amount

Total amount of all billed charges for this claim

The sum of all the charges for the claim from Charges --► Charge <Charge> as posted

CLM05 - 1

R

Facility Code

11 - Office
12 - Home   
21 - Inpatient Hospital
22 - Outpatient Hospital
23 - Emergency Room - Hospital
24 - Ambulatory Surgical Center
50 - Federally Qualified Health Center

Based on the posted Charges --►Charge <Facility> code Intellect reads Utility --► Facility. The Utility --►Facility <Place Of Service> 

CLM05 - 2

O

Facility Code Qualifier

not used

Utility --►Facility <Type>

CLM05 - 3

R

Claim Frequency Type Code

1 - Original (admit through discharge claim)
6 - Corrected (adjustment of prior claim)
7 - Replacement (Replacement of Prior Claim)
8 - Void (void/cancel of prior claim)

Charges --► Encounter <Claim Frequency Code>

CLM06

R

Provider Signature on File

Indication whether provider's signature is on file.
N-No, Y-Yes

Utility --►Insurance < Message Box 12 & 13 >

CLM07

R

Provider Accept Assignment Code

Assignment of benefits indicator. A “Y” value indicates insured or authorized person authorizes benefits to be assigned to the provider; an “N” value indicates benefits have not been assigned to the provider

If Y has been entered in the Registration -►Patient-► Insurance<Assignment> field, then “Y” will be used. If N has been entered, then the “N” will be marked. If the patient's insurance screen <Assignment> field default was modified at the time of posting charges or through the Charge --►Modify screen, then the Charges --► Charge OR Charges --►Modify <ASI> value will be used.

CLM08

R

Benefits Assignment Certification Indicator

Insured or authorized person authorizes benefits to be assigned to the provider.
N-No, Y-Yes

Utility --►Insurance <Assignment (Y/N/C)>

CLM09

R

Release of Information Code

The provider has on file a signed statement by the patient authorizing the release of medical data to other organizations.
A-appropriate release  
I-informed consent  
M-provider has limited ability to release data  
N-Not allowed to release info  
O-payor on file  
Y-permitted to release data

Entering a value in Utility --►Insurance < Message Box 12 & 13 > will enter a "Y"

CLM10

S

Patient Signature Source Code

Required if Patient Signature on file is checked Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider

Entering a value in Utility --►Insurance < Message Box 12 & 13 > will enter a "Y"

CLM11-1

S

Accident/Employment/Related Causes

Patient's Condition Related To:

Charges --► Encounter <Related: Accident (A/O/N)>

CLM11-2

S

Accident/Employment/Related Causes

Patient's Condition Related To:

Charges --► Encounter <Employment (Y/N)>                                                       

CLM11-3

S

Accident/Employment/Related Causes

Intellect will complete the state code

CLM20

S

Delay Reason Code

Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules Administration Delay in the Prior Approval Process Other

Charges --► Encounter <Delay Reason Code>

DTP 454

S

Date - Initial Treatment

Required for spinal manipulation certifications if different than information at claim level

Charges --► Encounter <Initial Treatment>

DTP 438

S

Date-Similar Symptom

Required if line value is different than value given at claim level (Loop ID-2300) and claim involves services to a patient experiencing symptoms similar or identical to previously reported symptoms.

Charges --► Encounter <Similar Symptom Date>

DTP 439

S

Date - Accident

Required if CLM11-1, CLM11-2, or CLM11-3 = AA, AB, AP or OA.

Charges --► Encounter <Injury Date>

DTP 455

S

Date - X-Ray

Required for spinal manipulation certifications if different than information at claim level

Charges --► Encounter <X_Ray Date>

DTP 360

S

Date - Disability From

Required on claims/encounters involving disability where, in the opinion of the provider, the patient, after having been absent from work for reasons related to the disability, was or will be able to perform the duties normally associated with his/her work.

Charges --► Encounter <Disability From>

DTP 361

S

Date - Disability To

Required on claims involving disability where, in the opinion of the provider, the patient was or will be unable to perform the duties normally associated with his/her work.

Charges --► Encounter <Disability To>

DTP 296

S

Date - Unable To Work To

Required on claims where this information is necessary for adjudication of the claim (e.g., workers compensation claims involving absence from work).

Charges --► Encounter <TO>

DTP 435

S

Date - Admission Date

Required on all ambulance claims/encounters when the patient was known to be admitted to the hospital. Also required on inpatient medical visits claims/encounters.

Charges --► Encounter <Hospitalization From>

DTP 096

S

Date - Discharge Date

Required for inpatient claims when the patient was discharged from the facility and the discharge date is known.

Charges --► Encounter <Hospitalization To>

DTP 090

S

Date - Assumed Care

When Physician “B” submits a claim/encounter “B” will use code “090 - Report Start” to indicate the date they assumed care of this patient from Surgeon “A”.

Charges --► Encounter <Report Start>

DTP 091

S

Date - Relinquished Care

Relinquished Care Date is the date the provider filing this claim ceased post-operative care

Charges --► Encounter <Report End>

PWK01

O

Attachment Report Type Code

Indicates type of report added

Charges --► Encounter <Report Type Code>

PWK02

O

Report Transmission Code

Indicates method of transmission R AA Available on Request at Provider Site This means that the paperwork is not being sent
with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.
BM By Mail.
EL Electronically Only Use to indicate that attachment is being transmitted in a separate X12 functional group.
EM E-Mail
FX By Fax

Charges --► Encounter <Report Transmission Code>

PWK04

O

Entity Identifier Code

AC Automatically entered by Intellect

PWK06

O

Identification Code

Identification Code

Charges --► Encounter <Identification Code>

REF*4N

S

Exception Code

Required when providers are required by state law (e.g., New York State Medicaid) to obtain authorization for specific services but, for the reasons listed in REF02, performed the service without obtaining the service authorization. Check with your state Medicaid to see if this applies in your state

Charges --► Encounter <Exception Code>

REF*G1

O

Prior Authorization or Referral Number

Charges --► Encounter <Authorization No>

REF*EA

O

Medical Record Number

Registration  --► Patient <Patient Account No>

NTE

O

Note/Special Instruction

To transmit information in a free-form format, if necessary, for comment or special instruction

363

NTE01

O

Note Reference Code

ADD: Additional Information or DGN: Diagnosis Description. Automatically entered by Intellect

Automatically entered by Intellect

352

NTE02

O

Description

A free-form description to clarify the related data elements and their content

Charges --► Encounter <Box 19 Claim Notes>

231

HI

S

Health Care Diagnosis Code

Required on all claims/encounters except claims for which there are no diagnoses

HI1

R

HEALTH CARE DIAGNOSIS CODE

The diagnosis listed in this element is assumed to be the principal diagnosis.

Based on the order entered at the time of posting (Charges --► Charge), the ICD-9 codes from the Utility --►Diagnosis <ICD9 Code> field for the dates of service(s) requested.

HI2

R

HEALTH CARE DIAGNOSIS CODE

Required if needed to report an additional diagnoses and if the preceding HI data elements have been used to report other diagnoses.

Based on the order entered at the time of posting (Charges --► Charge), the ICD-9 codes from the Utility --►Diagnosis <ICD9 Code> field for the dates of service(s) requested.

2310A

250

NM1

Individual or Organization Name

Contains Referring Provider information

098

NM101

S

Entity Identifier Code

DN - Referring Provider

Automatically entered by Intellect

1065

NM102

S

Entity Type Qualifier

Code qualifying the type of entity:

1 = Person. Automatically entered by Intellect

1035

NM103

S

Name Last or Organization Name

Referring Provider Last Name

Utility --►Referring <Last Name>

1036

NM108

S

Name First

Referring Provider First Name

Utility --►Referring  <First Name>

66

NM108

S

Identification Code Qualifier

XX Automatically entered by Intellect

67

NM109

S

Identification Code

Referring Provider's National Provider Identifier

Utility --►Referring  <NPI>

128

REF01

S

Reference Identification Qualifier

1G  Referring Provider UPIN

127

REF02

S

Reference Identification

Referring Provider Secondary Identifier

Utility --►Referring  <UPIN>

128

REF01

S

Reference Identification Qualifier

EI Employer’s Identification Number (Tax ID Qualifier)

127

REF02

S

Reference Identification

If the NPI is present in NM108 and NM109, then the Federal Tax Id Number is required in the REF segment.

Utility --►Referring <Tax ID>

2310B

250

NM1

O

Individual or Organization Name

Contains Rendering Provider information

NM101

R

Entity Identifier Code

82 - Rendering Provider

Automatically entered by Intellect

NM102

R

Entity Type Qualifier

1 - Person

1 = Person. Automatically entered by Intellect

1035

NM103

R

Name Last or Organization Name

Rendering Provider's last name

Utility --► Provider <Last Name> for the Provider selected Charges --► Charge <Billing Prv>

1036

NM104

R

Name First

Rendering Provider’s first name

Utility --► Provider <First Name> for the Provider selected Charges --► Charge <Billing Prv>

66

NM108

R

Identification Code Qualifier

XX Automatically entered by Intellect

67

NM109

R

Identification Code

Rendering Provider's National Provider Identifier

Utility --►Provider <NPI>

128

REF01

O

Reference Identification Qualifier

G2 Provider Commercial Number

127

REF02

S

Reference Identification

Rendering Provider Secondary Identifier

Intellect will select based on the program’s hierarchy. Intellect will first look in the Utility --►Provider --►Provider Facility screen for a match of the Billing Provider, Insurance, and Facility. If a match is not found the program will look to Utility --►Provider --►Provider Provider screen for a match of the Billing Provider and Insurance. If a match is not found in either table: Intellect will use the information set up in the Utility --► Provider screen.-- Then dependent on the screen selected one of these fields  Provider --► Facility: <HCFA Box 24 J>. Provider --► Provider <HCFA Box 24 J>.Provider <HCFA Box 24 J1>, <HCFA Box 24 J2>, or <HCFA Box 24 J3> will  be used.

128

REF01

S

Reference Identification Qualifier

EI Employer’s Identification Number (Tax ID Qualifier)

Automatically entered by Intellect

127

REF02

S

Reference Identification

If the NPI is present in NM108 and NM109, then the Federal Tax Id Number or the Social Security Number is required in the REF segment.

Intellect will select based on the program’s hierarchy. Intellect will first look in the Utility --►Provider --►Provider Facility screen for a match of the Billing Provider, Insurance, and Facility. If a match is not found the program will look to Utility --►Provider --►Provider /Provider screen for a match of the Billing Provider and Insurance. If a match is not found in either table: Intellect will use the information set up in the Utility --► Provider screen <I.R.S.Id>,

2310D

250

NM1

S

Individual or Organization Name

Contains Service Facility information

NM1

NM101

S

Entity Identifier Code

FA - Service Facility.

 Utility --►Facility <Type>

NM102

S

Entity Type Qualifier

2 - Non-Person.

 Automatically entered by Intellect

NM103

S

Name Last or Organization Name

Service Facility Name

Utility --►Facility<Name>

66

NM108

S

Identification Code Qualifier

XX Automatically entered by Intellect

Automatically entered by Intellect

67

NM109

S

Identification Code

Facility National Provider Identifier

Utility --►Facility<NPI>

265

N3

O

Address Information

166

N301

R

Address 1

Service Facility's Address 1

Utility --►Facility<Address>

270

N4

O

Geographic Location

City, state, zip

N401

R

City

Service Facility's City

Utility --►Facility<City>

N402

R

State

Service Facility's State

Utility --►Facility<Zip State>

N403

R

Zip Code

Service Facility's Zip Code

Utility --►Facility<Zip Code>

271

REF

O

REF Reference Identification

128

REF01

R

Reference Identification Qualifier

Code qualifying the Reference Identification based on Insurance billed.
1A Blue Cross Provider Number
1B Blue Shield Provider Number
1C Medicare Provider Number
1D Medicaid Provider Number
1G Provider UPIN Number

Automatically entered by Intellect

1127

REF02

R

Reference Identification

Laboratory/Facility Secondary Identification Number

Utility --►Facility<Provider 1>,<Provider 2>, or <Provider 3> based on Insurance <Selection (1/2/3)> for insurance being billed

2320 

318

SBR

S

OTHER SUBSCRIBER INFORMATION

Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber, Subscriber of the Other Insurance Carriers, School, or Employer Information for that Subscriber.

1138

SBR01

R

Payer Responsibility Sequence Number Code

P Primary                                                                                    S Secondary                                                                                T Tertiary

Registration --► Patient --► Insurance screen <Primary/Secondary>

1069

SBR02

R

Patient Relationship to Insured

Registration --► Patient --► Insurance screen <Relationship to Insured>

83

SBR03

S

Insured Group or Policy Number

Required if the subscriber’s payer identification includes Group or Plan Number. This data element is intended to carry the subscriber’s Group Number, not the number that uniquely identifies the subscriber

Registration --► Patient secondary insurance screen <Subscriber Number> field.

93

SBR04

S

Other Insured Group or Policy Name

Required if the subscriber’s payer identification includes a Group or Plan Name

Registration --► Patient Insurance <Type> field for secondary insurance screen

1336

SBR05

R

Insurance Type Code

Code identifying the type of insurance policy within a specific insurance program

Registration --► Patient Insurance <Claim Filing Indicator> field for secondary insurance screen

1032

SBR09

S

Claim filing indicator code

Required when using Plan ID

Registration --► Patient Insurance <Company Name> field for secondary insurance screen

DMG

S

Subscriber Demographic Information

1250

DMG01

R

Date Time Period Format Qualifier

1251

DMG02

R

Date Time Period

Other Insured Birth Date

If the patient is the insured, the date of birth will come from the Registration --► Patient --► <DOB> field. If the patient is a dependent, the date of birth will come from the Registration --► Patient --►Insurance <Insured DOB>

1068

DMG03

R

Gender Code

Other Insured Gender Code

If the patient is the insured, the gender will come from the Registration --► Patient --► <Gender> field. If the patient is a dependent, the gender will come from the Registration --► Patient --►Insurance <Gender>

OI

R

Other Insurance Coverage Information

1073

OI03

R

Yes/No Condition or Response Code

The assignment of benefits indicator. A “Y” value indicates insured or authorized person authorizes benefits to be assigned to the provider; an “N” value indicates benefits have not been assigned to the provider.

If Y has been entered in the Registration -►Patient-► Insurance<Assignment> field for the secondary insurance, then “Y” will be used. If N has been entered, then the “N” will be marked. If the patient's secondary insurance screen <Assignment> field default was modified at the time of posting charges or through the Charge --►Modify screen, then the Charges --► Charge OR Charges --►Modify <ASI> value will be used.

1351

OI04

S

Patient Signature Source Code

Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider

Entering a value Utility --►Insurance < Message Box 12 & 13 > will enter a "Y"

1363

OI06

R

Release of Information Code

Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations

Entering a value Utility --►Insurance < Message Box 12 & 13 > will enter a "Y"

2330A

R

OTHER SUBSCRIBER NAME 

2330

NM1

O

Individual or Organizational Name

Segments NM1-N4 contain patient name and address information of the insurance carriers referenced in loop 2320.

98

NM101

R

Entity Identifier Code

Code identifying an organizational entity, a physical location, property or an individual. Automatically entered by Intellect IL = Subscriber

Automatically entered by Intellect

1065

NM102

R

Entity Type Qualifier

Automatically entered by Intellect 1 = Person

Automatically entered by Intellect

1035

NM103

R

Name Last or Organization Name

Other Insured Last Name

If the patient is the insured, Last Name will come from the Registration --► Patient --► <Last Name> field. If the patient is a dependent, the Last Name will come from the Registration --► Patient --►Insurance <Last Name> for the secondary insurance

1036

NM104

R

Name First

Other Insured First Name

If the patient is the insured, First Name will come from the Registration --► Patient --► <First Name> field. If the patient is a dependent, the Last Name will come from the Registration --► Patient --►Insurance <Insured First Name> for the secondary insurance

66

NM108

R

Identification Code Qualifier

The code MI is intended to be the subscriber’s identification number as assigned by the payer. Payers use different terminology to convey the same number. Therefore the 837 Professional Workgroup recommends using MI – Member Identification Number to convey the following terms: Insured’s ID, Subscriber’s ID, Health Insurance Claim Number (HIC), etc

67

NM109

R

Identification Code

Other Subscriber Primary Identifier

Utility --►Insurance <Subscriber No> for Registration --► Patient secondary insurance

N3

O

Address Information

166

N301

R

Address Information

Other Insured Address Line

If the patient is the insured, the address will come from the Registration --► Patient --► <Address> field. If the patient is a dependent, the address will come from the Registration --► Patient --►Insurance <Address> for the secondary insurance

N4

O

Geographic Location

19

N401

S

City Name

Other Insured City Name

If the patient is the insured, the city name will come from the Registration --► Patient --► <City> field. If the patient is a dependent, the city name will come from the Registration --► Patient --►Insurance <City> for the secondary insurance

156

N402

S

State or Province Code

Other Insured State Code

If the patient is the insured, the state name will come from the Registration --► Patient --► <State> field. If the patient is a dependent, the state name will come from the Registration --► Patient --►Insurance <State> for the secondary insurance

116

N403

S

Postal Code

Other Insured Postal Zone or ZIP Code

If the patient is the insured, the Zip code will come from the Registration --► Patient --► <Zip Code> field. If the patient is a dependent, the Zip code will come from the Registration --► Patient --►Insurance <Zip Code> for the secondary insurance

2330B

R

OTHER PAYER NAME

Submitters are required to send all known information on other payers in this Loop ID-2330.

325

NM1

R

Individual or Organizational Name

To supply the full name of an individual or organizational entity

98

NM101

R

Entity Identifier Code

Code identifying an organizational entity, a physical location, property or an  Individual PR= Payer

1065

NM102

R

Entity Type Qualifier

2 = Non-Person Entity

1035

NM103

R

Name Last or Organization Name

Other Payer Last or Organization Name

Registration --►Patient --► Insurance <Insurance Company Name> for the secondary insurance

66

NM108

R

Identification Code Qualifier

PI Payor Identification

67

NM109

R

Identification Code

2400 

R

SERVICE LINE

The Service Line LX segment begins with 1 and is incremented by one for each additional service line of a claim. The LX functions as a line counter.

LX01

R

LX Assigned Number

The service line number incremented by 1 for each service line.

SV1

O

Professional Service

To specify the claim service detail for a Health Care professional

235

SV101-1

R

Product/Service ID Qualifier

HC= Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

234

SV101 - 2

R

Product/Service ID Qualifier

Procedure Code

Based on the patient’s assigned insurance Utility --►Insurance <Code (R/C/E/U)> field entry, the corresponding code from Utility --►Procedure < Code R>, <Code C>, <Code E>, <Revenue Code> entered at the time of posting the panel code  Charges --► Charge) will be used here

762

SV102

R

Monetary Amount

Submitted charge amount

This will use the amount from the posted Charges --► Charge <Charge>.

355

SV103

R

Unit or Basis for Measurement Code

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken. UN = Unit

380

SV104

R

Quantity

Units or Minutes

The value entered in the Utility --►Procedure <Days & Units> field will be used. If this value is modified at the time of posting, then the Charges --►Charge <Qty> entry will be used...

1331

SV105

S

Facility Code Value

Place of Service Code

Based on the posted Charges --►Charge <Facility> code, Intellect uses the Utility --►Facility <Place Of Service> code.

1328

SV107

S

Diagnosis Code Pointer

Required if the service relates to that specific diagnosis and is needed to substantiate the medical treatment. Acceptable values are 1 through 8, inclusive.

The <RDX> field entry for charges being billed (Charges --► Charge OR Charges --►Modify).Medicare will only accept one related diagnosis per charge/procedure

1073

SV109

S

Emergency Indicator

The emergency-related indicator; a “Y” value indicates service provided was emergency related; an “N” value indicates service provided was not emergency related.

If the patient’s insurance coverage is Medi-Cal (Medicaid) (Utility --► Insurance <Insurance Type> = D) this will come from the patient’s Encounter screen <Emergency (Y/N)> field (Charges/Encounter) when the encounter number is associated with the charges being billed (Charges --►Charge OR Charges --► Modify <EN#> field).

DTP472

R

Date Service Date

374

DTP02

R

Date Service Date

Date Format Qualifier D8. Uses RD8 in DTP02 to indicate begin/end or from/to dates.

1250

DTP03

R

Date Service Date

Date of Service

Charges --►Charge <From/Date>

DTP304

S

Last Seen Date

1250

DTP02

Date Time Period Format Qualifier

Date Format Qualifier D8

1251

DTP03

S

Last Seen Date

The most current date that the patient was seen by a physician. Required when claim is from an independent physical therapist, occupational therapist, or physician providing routine foot care if the date last seen by an attending or supervising physician is different from that listed at the claim level (Loop ID-2300).

Charges --►Encounter <Date Last Seen>

DTP431

S

ONSET OF CURRENT SYMPTOM/ILLNESS

Required if line value is different than value given at claim level (Loop ID-2300) and claim involves services to a patient experiencing

symptoms similar or identical to previously reported symptoms.

1250

DTP02

R

Date Time Period Format Qualifier

Date Format Qualifier D8

1251

DTP03

R

Date Time Period

Required on claims involving services to a patient experiencing symptoms similar or identical to previously reported symptoms.

Charges --►Encounter <First Symptom>

DTP453

S

DATE - ACUTE MANIFESTATION

Required for spinal manipulation certifications if different than information at claim level (Loop ID-2300).

1250

DTP02

R

Date Time Period Format Qualifier

Date Format Qualifier D8

1251

DTP03

R

Acute Manifestation Date

Required for spinal manipulation certifications if different than information at claim level (Loop ID-2300).

Charges --►Encounter <Acute Manifestation>

REF*6R

S

Line Item Control Number

GE

R

TRANSACTION SET TRAILER

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

IEA

R

Function Group Trailer

Functional Group Trailer ends a group of related transaction sets.

R

Interchange Control Trailer

To define the end of an interchange of zero or more functional groups and interchange-related control segments