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Government of the Virgin Islands of the United States
Date of Publication: 02/06/2013
Version: 1.5
USVI
HEALTH CARE CLAIM
837
Companion Guide
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DISCLAIMER
The DXC Technology Companion Guide for USVI Medicaid is subject to change prior to January 1,
2013 or at the instruction of the Department. Therefore, it is the responsibility of the trading
partner to ensure that the latest version of this guide is used when designing\building NX12 5010
EDI transactions. The trading partner should frequently check for updates to the companion guide.
DXC Technology accepts no liability for any costs that the trading partner may incur that arise from
or are related to changes to the companion guide.
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Preface
This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata
adopted under HIPAA clarifies and specifies the data content when exchanging electronically with
DXC Technology. Transmissions based on this companion guide, used in tandem with the v5010
ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. This
Companion Guide is intended to convey information that is within the framework of the ASC X12N
Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to
convey information that in any way exceeds the requirements or usages of data expressed in the
Implementation Guides.
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EDITOR'S NOTE
This page is blank because major sections of a book should begin on a right hand page.
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Table of Contents
INTRODUCTION ................................................................................................................................................................... 7
SCOPE ...................................................................................................................................................................................... 8 OVERVIEW ............................................................................................................................................................................... 8 REFERENCES ............................................................................................................................................................................ 8 ADDITIONAL INFORMATION .................................................................................................................................................... 8
GETTING STARTED ............................................................................................................................................................... 8
WORKING WITH DXC TECHNOLOGY ........................................................................................................................................ 8 TRADING PARTNER REGISTRATION ......................................................................................................................................... 8 CERTIFICATION AND TESTING OVERVIEW ............................................................................................................................... 9 TESTING WITH THE PAYER ....................................................................................................................................................... 9
CONNECTIVITY WITH THE PAYER/COMMUNICATIONS ........................................................................................................ 9
PROCESS FLOWS ...................................................................................................................................................................... 9 TRANSMISSION ADMINISTRATIVE PROCEDURES .................................................................................................................... 9 RE-TRANSMISSION PROCEDURE .............................................................................................................................................. 9 COMMUNICATION PROTOCOL SPECIFICATIONS ................................................................................................................... 10 PASSWORDS .......................................................................................................................................................................... 10
CONTACT INFORMATION ................................................................................................................................................... 10
EDI CUSTOMER SERVICE ........................................................................................................................................................ 10 EDI TECHNICAL ASSISTANCE .................................................................................................................................................. 10 PROVIDER SERVICE NUMBER ................................................................................................................................................. 10 APPLICABLE WEBSITES/E-MAIL .............................................................................................................................................. 10
CONTROL SEGMENTS AND ENVELOPES ............................................................................................................................. 10
VALID DELIMITERS FOR USVI MEDICAID ......................................................................................................................................... 10 ISA-IEA ................................................................................................................................................................................... 11 GS-GE ..................................................................................................................................................................................... 12 ST-SE ...................................................................................................................................................................................... 12
PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ......................................................................................................... 13
ACKNOWLEDGEMENTS AND/OR REPORTS ........................................................................................................................ 13
REPORT INVENTORY .............................................................................................................................................................. 13
TRADING PARTNER AGREEMENTS ..................................................................................................................................... 14
TRADING PARTNERS .............................................................................................................................................................. 14
TRANSACTION SPECIFIC INFORMATION ............................................................................................................................. 14
FIELD DEFINITIONS ................................................................................................................................................................ 14 837 PROFESSIONAL TRANSACTION COMPANION GUIDE ...................................................................................................... 15 837 INSTITUTIONAL TRANSACTION COMPANION GUIDE ...................................................................................................... 18 837 DENTAL TRANSACTION COMPANION GUIDE .................................................................................................................. 24 ATYPICAL PROVIDERS ............................................................................................................................................................ 27 ADDITIONAL PROVIDER INFORMATION ................................................................................................................................ 28
APPENDICES ...................................................................................................................................................................... 29
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IMPLEMENTATION CHECKLIST ....................................................................................................................................................... 29 TRANSMISSION EXAMPLES ........................................................................................................................................................... 29
TA1 Interchange Acknowledgement ................................................................................................................................. 29 999 Implementation Acknowledgement for Health Care Insurance ................................................................................. 30 824 Application Advice ...................................................................................................................................................... 30 Business Rejection Report ................................................................................................................................................. 32
FREQUENTLY ASKED QUESTIONS .................................................................................................................................................. 32 CHANGE SUMMARY .................................................................................................................................................................... 32
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INTRODUCTION
This guide describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be
detailed with the use of a table. The tables contain a row for each segment that DXC Technology
has something additional, over and above, the information in the IGs. That information can:
Limit the repeat of loops, or segments
Limit the length of a simple data element
Specify a sub-set of the IGs internal code listings
Clarify the use of loops, segments, composite and simple data elements
Any other information tied directly to a loop, segment, composite or simple data element
pertinent to trading electronically with DXC Technology
In addition to the row for each segment, one or more additional rows are used to describe DXC
Technology’s usage for composite and simple data elements and for any other information. Notes
and comments should be placed at the deepest level of detail. For example, a note about a code
value should be placed on a row specifically for that code value, not in a general note about the
segment.
The following table specifies the columns and suggested use of the rows for the detailed
description of the transaction set companion guides.
Page
#
Loop
ID
Reference Name Codes Length Notes/Comments
193 2100C NM1 Subscriber
Name
This type of row always exists to
indicate that a new segment has
begun. It is always shaded at 10
percent and notes or comment about
the segment itself goes in this cell.
195 2100C NM109 Subscriber
Primary
Identifier
15 This type of row exists to limit the
length of the specified data element.
196 2100C REF Subscriber
Additional
Identification
197 2100C REF01 Reference
Identification
Qualifier
18, 49,
6P, HJ,
N6
These are the only codes transmitted
by DXC Technology.
Plan Network
Identification
Number
N6 This type of row exists when a note
for a particular code value is
required. For example, this note may
say that value N6 is the default. Not
populating the first three columns
makes it clear that the code value
belongs to the row immediately
above it.
218 2110C EB Subscriber
Eligibility or
Benefit
Information
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Page
#
Loop
ID
Reference Name Codes Length Notes/Comments
231 2110C EB13-1 Product/Service
ID Qualifier
AD This row illustrates how to indicate a
component data element in the
Reference column and how to specify
that only one code value is
applicable.
SCOPE
This companion guide documents the transaction type listed below and further defines situational
and required data elements that are used for processing claims for programs administered by USVI
Medicaid. This document is not the complete EDI transaction format specifications. Refer to the
ASC X12N Implementation Guides or 5010 TR3s for information not supplied in this document,
such as code lists, definitions, and edits.
OVERVIEW
Data elements, segments, and loops not included in this guide are not used for processing claims
by USVI Medicaid, but will still be sent if the information is required for compliance with the ASC
X12N version 5010A2 format.
REFERENCES
The ASC X12N Implementation Guides or 5010 TR3s (Type 3 Technical Report) are standards
developed by the X12 committee and published by the Washington Publishing Company (WPC).
http://store.x12.org/store/healthcare-5010-consolidated-guides
ADDITIONAL INFORMATION
Assumptions regarding the reader
You are interested in reducing error, maximizing efficiency, and saving money.
USVI Medicaid encourages all providers to receive and make use of the standard HIPAA
837 Healthcare Claim.
Advantages / Benefits of EDI
The 837 Healthcare Claim allows for electronic submission of claims data sent to USVI
Medicaid using computer software.
GETTING STARTED
WORKING WITH DXC TECHNOLOGY
Please visit http://www.vimmis.com for information.
For any questions, or to begin testing, please contact the DXC Technology EDI Helpdesk at 1-855-
248-7536 or email us at VIEDIHelpdesk@molinahealthcare.com.
TRADING PARTNER REGISTRATION
A trading partner is defined as any entity with which DXC Technology exchanges electronic data.
The term electronic data is not limited to HIPAA X12 transactions. USVI Medicaid’s Health PAS
system supports the following categories of trading partner:
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Provider
Billing Agency
Clearinghouse
Other
DXC Technology will assign trading partner IDs to support the exchange of X12 EDI transactions
for providers, billing agencies and clearinghouses.
To obtain a trading partner ID please visit our website at: http://www.vimmis.com or contact us at
1-855-248-7536.
CERTIFICATION AND TESTING OVERVIEW
All trading partners must be authorized to submit production EDI transactions. Any trading partner
may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control
Header (ISA) of an X12 file, indicates if a file is test or production. Authorization is granted on a
per transaction basis. For example, a trading partner may be certified to submit 837P professional
claims but not certified to submit 837I institutional claim files.
Refer to the USVI Health Pas Web Portal Provider User Guide for more information. The user guide
can be found at https://www.vimmis.com/user%20guides/forms/allitems.aspx.
TESTING WITH THE PAYER
Trading partners must submit three test files of a particular transaction type, with a minimum of
fifteen transactions within each file, and have no failures or rejections to become certified for
production. Review the “EDI Certification Status” page of Health PAS-OnLine under the “Account
Maintenance” menu option to verify when testing for a particular transaction has been completed.
The EDI Certification Status page is found by logging in to your trading partner account on the
Health PAS-OnLine Website (www.vimmis.com).
Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may be
found in the Business Scenarios and Transmission Examples appendices found at the end of this
companion guide.
CONNECTIVITY WITH THE PAYER/COMMUNICATIONS
PROCESS FLOWS
The 837 Healthcare Claim transaction process flow is not available at this time and will be updated
when mandated by CAQH operating rules.
TRANSMISSION ADMINISTRATIVE PROCEDURES
X12 files can be uploaded via Health PAS-OnLine File Exchange X12 Upload.
837 Healthcare Claim transaction files, Acknowledgments and Responses to transactions submitted
via the Health PAS-OnLine website can be accessed by selecting Claims (837) under the File
Exchange menu.
RE-TRANSMISSION PROCEDURE
ISA13 – Interchange Control Number needs to be unique to each file and Trading Partner ID.
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COMMUNICATION PROTOCOL SPECIFICATIONS
The following communications protocols are available for sending and receiving the ASC X12N 837
Health Care Claim transactions.
Refer to the “Health Care Claims (837)” ASC X12N Implementation Guide for more information on
submitting Batch and Real-time transactions.
http://store.x12.org/store/healthcare-5010-consolidated-guides
PASSWORDS
Trading Partners create their own password at time of registration and are required to update it
every 60 days as per the Health PAS-OnLine requirements. Password must be at least eight (8)
characters consisting of an upper and lower case letter, a special character such as # or * or ^
(except ,) and a number. A password may not start with the first three characters of the User
Name. The web portal account will become locked after five incorrect password attempts. The
user will need to utilize the “Unlock” link to reset the password or contact the EDI Helpdesk.
CONTACT INFORMATION
EDI CUSTOMER SERVICE
Contact DXC EDI Helpdesk at 1-855-248-7536 or email VIEDIHelpdesk@molinahealthcare.com.
EDI TECHNICAL ASSISTANCE
Contact DXC EDI Helpdesk at 1-855-248-7536 or email VIEDIHelpdesk@molinahealthcare.com.
PROVIDER SERVICE NUMBER
Contact Provider Services at 1-340-715-6929 or email vimmis@dhs.vi.gov
APPLICABLE WEBSITES/E-MAIL
The email addresses below can be used in contacting USVI Medicaid’s EDI Support, Provider
Services, and the Provider Enrollment department. These groups can provide assistance and
answer questions relating to EDI file submissions, provider enrollment, and services.
Website -- http://www.vimmis.com
EDI Support – VIEDIHelpdesk@molinahealthcare.com
Provider Services – vimmis@dhs.vi.gov
Provider Enrollment – vimmis@dhs.vi.gov
CONTROL SEGMENTS AND ENVELOPES
Valid Delimiters for USVI Medicaid
A delimiter is a character used to separate two data elements or component elements or to
terminate a segment. The delimiters are an integral part of the data.
USVI Medicaid does not require the use of specific values for the delimiters used in electronic
transactions. The suggested values are included in the specifications below.
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Definition ASCII Decimal Hexadecimal
Segment Separator ~ 126 7E
Element Separator * 42 2A
Compound Element Separator : 58 3A
ISA-IEA
The following ISA/IEA fields are the sender and receiver specific information listed in the 837
transactions. The ISA segment must equal a 105 byte fixed length record, followed by a segment
terminator delimiter equaling a total of 106 bytes. For all other fields, see the transaction specific
information table in section Transaction Specific Information.
ISA06 – Interchange Sender ID will contain the DXC assigned trading partner ID.
ISA08 – Interchange Receiver ID will contain VI_MMIS_4_DXCMS.
ISA13 – Sender generated Interchange Control Number. This number must be unique in each file
submission and will match the number in IEA02.
ISA - INTERCHANGE CONTROL HEADER SEGMENT
Reference Definition Values
ISA01 Authorization Information
Qualifier
00
ISA02 Authorization Information [space fill]
ISA03 Security Information
Qualifier
00
ISA04 Security Information [space fill]
ISA05 Interchange ID Qualifier ZZ
ISA06 Interchange Sender ID Insert with the unique number found on
your USVI Transaction Information Form.
ISA07 Interchange ID Qualifier ZZ
ISA08 Interchange Receiver ID VI_MMIS_4_DXCMS
ISA09 Interchange Date The date format is YYMMDD
ISA10 Interchange Time The time format is HHMM
ISA11 Repetition Separator ^
ISA12 Interchange Control Version
Number
00501
ISA13 Interchange Control
Number
Must be identical to the interchange trailer
IEA02 (defined by sending Trading Partner)
ISA14 Acknowledgment Request 1
ISA15 Usage Indicator T= Test Data
P = Production Data
ISA16 Component Element
Separator
:
IEA - INTERCHANGE CONTROL TRAILER
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Reference Definition Values
IEA01 Number of included
Functional Groups
Count of included Functional Groups
IEA02 Interchange Control
Number
Must be identical to the value in ISA13
GS-GE
The following GS/GE fields are the sender and receiver specific information listed in the 837
transactions. For all other fields, see the transaction specific information table in section
Transaction Specific Information.
GS02 – Interchange Sender ID will contain the DXC assigned trading partner ID.
GS03 – Interchange Receiver ID will contain VI_MMIS_4_DXCMS.
GS06 – Sender generated Group Control Number, will match the number in GE02.
GS – FUNCTIONAL GROUP HEADER
Reference Definition Values
GS01 Functional Identifier Code HC = Health Care Claim (837)
GS02 Application Sender’s Code Must be identical to the value in ISA06
GS03 Application Receiver’s Code VI_MMIS_4_DXCMS
GS04 Date The date format is CCYYMMDD
GS05 Time The time format is HHMM
GS06 Group Control Number Assigned and maintained by the sender
GS07 Responsible Agency Code X
GS08 Version/Release/Industry
Identifier Code
Appropriate Version Code for the claim
GE – FUNCTIONAL GROUP TRAILER
Reference Definition Values
GE01 Number of Transaction Sets
Included
Number of Transaction Sets included
GE02 Group Control Number Must be identical to the value in GS06
ST-SE
The following ST/SE fields are the sender and receiver specific information listed in the 837
transactions. For all other fields, see the transaction specific information table in section
Transaction Specific Information.
ST02 – Sender generated Transaction Set Control Number and must match the number in SE02.
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ST – TRANSACTION SET HEADER
Reference Definition Values
ST01 Transaction Set Identifier
Code
Code uniquely identifying a Transaction Set
ST02 Transaction Set Control
Number
Must be identical to the value in SE02
ST03 Implementation Guide
Version Name
Must be identical to the value in GS08
SE – TRANSACTION SET TRAILER
Reference Definition Values
SE01 Transaction Segment Count Total number of segments included in a
transaction set including ST and SE.
SE02 Transaction Set Control
Number
Must be identical to the value in ST02
For all other fields, see the transaction specific information table in section Transaction Specific
Information.
PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS
Listed below are the transmission constraints associated with the submission of the 837 Healthcare
claim transaction:
Only one Interchange per transmission
Only one transaction type per interchange
Maximum of 5,000 claims per transmission
Single transmission file size must be less than 5 MB
For DXC Technology specific business rules and limitation in association with the ASC X12N 837
Healthcare Claim transaction, refer to section Transaction Specific Information.
ACKNOWLEDGEMENTS AND/OR REPORTS
The acknowledgements and/or reports listed below are related to the submission of EDI
transactions by a trading partner. These acknowledgements and/or reports are downloaded via the
Heath PAS-OnLine Web portal or through FTP for those providers that submit transactions from an
FTP connection. Additional information about retrieving and interpreting acknowledgements and/or
reports can be found in the Transmission Example Appendix.
REPORT INVENTORY
TA1 – Interchange Acknowledgement. This acknowledgement is sent if requested by
setting ISA14 to ‘1’, or if ISA14 is set to ‘0’ and there is an error that needs to be
reported.
999 – Functional Acknowledgement. This acknowledgement file reports any errors found
while checking compliance against TR3 specifications, or acceptance of an EDI
transaction that meets the TR3 specifications for SNIP levels 1 and 2.
277 Claim Acknowledgement – This transaction is not mandated by HIPAA, but will be
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used to report claims that have been accepted for adjudication as well as those that are
not accepted due to compliancy errors when submitted through the 837 transaction.
824 Application Advice Report. This transaction is not mandated by HIPAA, but will be
used to report the results of data content edits of transaction sets. It is designed to
report rejections based on business rules such as; invalid diagnosis codes, invalid
procedure codes, and invalid provider numbers. The 824 Application Advice report does
not replace the 999 or TA1 transactions and will only be generated by Health PAS if
there are errors within the transaction for SNIP level 3 through 7.
BRR – Business Rejection Report. Health PAS also produces a readable version of the
824 called the Business Rejection Report (BRR). This report helps to facilitate the
immediate correction and re-bill of claims rejected during HIPAA validation for SNIP
levels 1 through 7.
TRADING PARTNER AGREEMENTS
TRADING PARTNERS
A trading partner is defined as any entity with which DXC exchanges electronic data. The term
electronic data is not limited to HIPAA X12 transactions. USVI Medicaid’s Health PAS system
supports the following categories of trading partner:
Provider
Billing Agency
Clearinghouse
Health Plan
DXC will assign trading partner IDs to support the exchange of X12 EDI transactions for providers,
billing agencies and clearinghouses, and other health plans.
All trading partners must be authorized to submit production EDI transactions. Any trading partner
may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control
Header (ISA) of an X12 file, indicates if a file is test or production. Authorization is granted on a
per transaction basis. For example, a trading partner may be certified to submit 837P professional
claims but not certified to submit 837I institutional claim files.
TRANSACTION SPECIFIC INFORMATION
Listed in the following tables are the specific requirements for submitting and processing an ASC
X12N 837 Healthcare Claim transaction file to DXC Technology. Use these guidelines in
conjunction with the official ASC X12N 837 TR3 document to submit 837 Healthcare Claim
transaction files.
FIELD DEFINITIONS
Label Column Definition
A The name of the loop as documented in the appropriate 837 TR3.
B A loop ID number used to identify a group of segments that are collectively
repeated in a serial fashion up to a specified maximum number of times as
documented in the appropriate 837 TR3.
C The field position number and segment number as specified in the appropriate
837 TR3.
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Label Column Definition
D The data element name as indicated in the appropriate 837 TR3.
E The Values and Comments further describing the appropriate 837 TR3 field data
that USVI Medicaid will accept.
837 PROFESSIONAL TRANSACTION COMPANION GUIDE
The 837 Professional Versions used in creating the guide.
Health Care Claim: Professional 005010X222 May 2006
Health Care Claim: Professional 005010X222A1 October 2007
Health Care Claim: Professional 005010X222A2 June 2010
Loop Name Loop
ID
Field
Position/
Segment
Data Element
Name/Page
Number from
Implementation
Guide
Valid Values
And/or
Comments
A B C D E
Version/Release/Industry
Identifier Code
GS08 Identification
Code
005010X222A1
Beginning of Hierarchical
Transaction
BHT02
Transaction Set
Purpose Code
‘00’ Original
Beginning of Hierarchical BHT06 Transaction Type ‘CH’ Chargeable
Transaction Code
Submitter Name 1000A NM109 Identification
Code
Insert with the unique
number found on
your USVI
Transaction
Information Form.
Submitter Contact
Information
1000A PER03 Communication
Number Qualifier
‘TE’ Telephone
Minimum
requirement, PER 05
–PER08 may also be
sent.
Receiver Name 1000B NM103 Name Last or
Organization
Name
VI_MMIS_4_DXCMS
Receiver Name 1000B NM109 Identification
Code
VI_MMIS_4_DXCMS
Billing Provider Name
2010AA NM108 Identification
Code Qualifier
‘XX’ National Provider
ID. Atypical Providers
refer to Atypical
Section.
Billing Provider Name
2010AA NM109 Identification
Code
Billing Provider
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Loop Name Loop
ID
Field
Position/
Segment
Data Element
Name/Page
Number from
Implementation
Guide
Valid Values
And/or
Comments
A B C D E
National Provider ID.
Usage changed to
situational.
Billing Provider Address 2010AA N403 Postal Code
Billing Provider Zip
Code must be the
full 9 digits
Subscriber Hierarchical
Level
2000B HL04 Hierarchical Child
Code
‘0’ No subordinate
HL Segment in the
Hierarchical
Structure
Subscriber Information 2000B SBR09 Claim Filing
Indicator Code
MC
Subscriber Name 2010BA NM102 Entity Type
Qualifier
‘1’ Person
Subscriber Name 2010BA NM108 Identification Code
Qualifier
‘MI’ Member
Identification
Number
Subscriber Name 2010BA NM109 Identification
Code
USVI Medicaid 10
digit Recipient
Number
Payer Name 2010BB NM103 Name Last or
Organization
Name
VI_MMIS_4_DXCMS
Payer Name 2010BB NM108 Identification Code
Qualifier
‘PI’ Payer
Identification
Payer Name 2010BB NM109 Identification
Code
VI_MMIS_4_DXCMS
Claim Information 2300 CLM01 Claim Submitter’s
Patient Account /
Identifier Number
Patient Control
Number
Claim Information 2300 CLM06 Yes/No Condition
or Response
Code
‘Y’ Yes
Claim Information 2300 CLM08 Yes/No Condition
or Response
Code
‘Y’ Yes
Health Care Diagnosis
Code
2300 HI01-2 Industry Code
Diagnosis Code
Required on all
claims.
Transportation claims
use 799.0 when
unknown.
Referring Provider Name 2310A NM108 Identification Code
Qualifier
‘XX’ National
Provider ID
Referring Provider Name 2310A NM109 Identification
Code
Referring Provider
National Provider ID
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Loop Name Loop
ID
Field
Position/
Segment
Data Element
Name/Page
Number from
Implementation
Guide
Valid Values
And/or
Comments
A B C D E
Rendering Provider
Name
2310B NM108 Identification Code
Qualifier
‘XX’ National
Provider ID
Rendering Provider
Name
2310B NM109 Identification
Code
Rendering Provider
National Provider ID
Rendering Provider Name 2310B PRV01 Provider Code ‘PE’ Performing
SBR-Other Subscriber
Information
2320 SBR09 Claim Filing
Indicator Code
Please ensure to
use the correct
indicator code(s)
when billing VI
Medicaid as a
secondary or
tertiary payer.
Do not send ‘MC’ in
this Position/
Segment for
secondary or
tertiary claims.
Valid values are:
‘11’ – Other
NonFederal
Programs
‘12’ – Preferred
Provider
Organization
(PPO)
‘13’ – Point of
Service (POS) ‘14’
– Exclusive
Provider
Organization
(EPO)
‘15’ – Indemnity
Insurance
‘16’ – Health
Maintenance
Organization
(HMO) Medicare
Risk
‘17’ – Dental
Maintenance
Organization
‘AM’ – Automobile
Medical
‘BL’ – Blue Cross/
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Loop Name Loop
ID
Field
Position/
Segment
Data Element
Name/Page
Number from
Implementation
Guide
Valid Values
And/or
Comments
A B C D E
Blue Shield
‘CH’ – Champus
‘CI’ – Commercial
Insurance Co
‘DS’ – Disability
‘FI’ – Federal
Employees
Program
‘HM’ – Health
Maintenance
Organization
‘LM’ – Liability
Medical
‘MA’ – Medicare
Part A
‘MB’ – Medicare
Part B
‘OF’ – Other
Federal Program
‘TV’ – Title V
‘VA’ – Veterans
Affairs Plan
‘WC’ – Workers’
Compensation
Health Claim
‘ZZ’ – Mutually
Defined
Line Adjustment 2430 CAS01 Claim Adjustment
Group Code
‘CR’ Correction and
Reversals
‘CO’ ‘OA’ ‘PI’ ‘PR’
Line Adjustment 2430 CAS02 Claim Adjustment
Reason Code
For adjustment
reason codes see
http://wpc-edi.com
Line Adjustment 2430 CAS03 Monetary Amount
Adjusted Amount
Line Level
Line Adjustment 2430 CAS04 Quantity/Adjusted
Units – Line Level
837 INSTITUTIONAL TRANSACTION COMPANION GUIDE
The 837 Institutional Versions used in creating the guide.
Health Care Claim: Institutional 005010X223 May 2006
Health Care Claim: Institutional 005010X223A1 October 2007
Health Care Claim: Institutional 005010X223A2 June 2010
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Loop Name Loop
ID
Field
Position/
Segment
Data Element
Name/Page
Number from
Implementation
Guide
Valid Values
And/or
Comments
A B C D E
Version/Release/Industry
Identifier Code
GS08 Identification
Code
005010X223A2
Beginning of Hierarchical
Transaction
BHT02
Transaction Set
Purpose Code
‘00’ Original
Beginning of Hierarchical
Transaction
BHT06
Transaction Type
Code
‘CH’ Chargeable
Submitter Name 1000A NM109 Identification
Code
Insert with the unique
number found on
your USVI
Transaction
Information Form.
Submitter Contact
Information
1000A PER03 Communication
Number Qualifier
‘TE’ Telephone
Minimum
requirement, PER 05
–PER08 may also be
sent.
Receiver Name 1000B NM103 Name Last or
Organization
Name
VI_MMIS_4_DXCMS
Receiver Name 1000B NM109 Identification
Code
VI_MMIS_4_DXCMS
Billing Provider Name
2010AA NM108 Identification
Code Qualifier
‘XX’ National Provider
ID. Atypical
Providers refer to
Atypical Section.
Billing Provider Name
2010AA NM109 Identification
Code
Billing Provider
National Provider ID.
Usage changed to
situational.
Billing Provider Address 2010AA N403 Postal Code
Billing Provider Zip
Code must be the
Full 9 digits
Subscriber Hierarchical
Level
2000B HL04 Hierarchical Child
Code
‘0’ No subordinate
HL Segment in the
Hierarchical
Structure
Subscriber Information 2000B SBR09 Claim Filing
Indicator Code
MC
Subscriber Name 2010BA NM102 Entity Type
Qualifier
‘1’ Person
Subscriber Name 2010BA NM108 Identification
Code Qualifier
‘MI’ Member
Identification
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Loop Name Loop
ID
Field
Position/
Segment
Data Element
Name/Page
Number from
Implementation
Guide
Valid Values
And/or
Comments
A B C D E
Number
Subscriber Name 2010BA NM109 Identification
Code
USVI Medicaid 10
digit Recipient
Number
Payer Name 2010BB NM103 Name Last or
Organization
Name
VI_MMIS_4_DXCMS
Payer Name 2010BB NM108 Identification
Code Qualifier
‘PI’ Payer
Identification
Payer Name 2010BB NM109 Identification
Code
VI_MMIS_4_DXCMS
Claim Information 2300 CLM01 Claim Submitter’s
Patient Account /
Identifier Number
Patient Control
Number
Claim Information 2300 CLM06 Yes/No Condition
or Response Code
‘Y’ Yes
Claim Information 2300 CLM08 Yes/No Condition
or Response Code
‘Y’ Yes
Discharge Hour 2300 DTP01 Date Time Period
Discharge Hour
‘096’
Claim Information 2300 DTP02 Date Time Period
Format Qualifier
‘TM’
Admission Date/Hour 2300 DTP01 Date Time
Qualifier
‘435’
Admission Date/Hour 2300 DTP02 Date Time Period
Format Qualifier
‘D8’ or ‘DT’
Admission Date/Hour 2300 DTP03 Date Time Period
Institutional Claim Code 2300 CL101 Admission Type
Code
Institutional Claim Code 2300 CL102 Admission Source
Code
Institutional Claim Code 2300 CL103 Patient Status
Code
Prior Authorization or
Referral Number
2300 REF01 Reference
Identification
Qualifier
‘G1’ Prior
Authorization
Number
Prior Authorization or
Referral Number
2300 REF02 Reference
Identification
Assigned Prior
Authorization
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Loop Name Loop
ID
Field
Position/
Segment
Data Element
Name/Page
Number from
Implementation
Guide
Valid Values
And/or
Comments
A B C D E
Prior
Authorization
Number
Number
Other Diagnosis Code 2300 HI01-2 Industry Code
Diagnosis Code
Use appropriate
Reference
Principal Procedure
Information
2300 HI01-1 Code List
Qualifier Code
‘BF’ International
Classification of
Diseases Clinical
Modification (ICD-
9CM)
Principal Procedure
Information
2300 HI01-2 Industry Code
Principal
Procedure Code
Principal Procedure
Code
Other Procedure
Information
2300 HI01-1 Code List
Qualifier Code
‘BQ’ International
Classification of
Diseases Clinical
Modification (ICD-9-
CM) Procedure
Other Procedure
Information
2300 HI01-2 Industry Code
Procedure Code
Other Procedure Code
Other Procedure
Information
2300 HI01-4 Date Time Period
Procedure Date
Attending Physician
Name
2310A NM108 Identification
Code Qualifier
‘XX’ National
Provider ID
Attending Physician
Name
2310A NM109 Identification
Code
Attending Physician
National Provider ID
Attending Physician
Name
2310A PRV01 Provider Code ‘AT’ Attending
Attending Physician
Name
2310A PRV02 Reference
Identification
Qualifier
‘PXC’ Health Care
Provider Taxonomy
Code
Attending Physician
Name
2310A PRV03 Reference
Identification
Provider Taxonomy
Code
Referring Provider Name 2310A NM108 Identification
Code Qualifier
‘XX’ National
Provider ID
Referring Provider Name 2310A NM109 Identification
Code
Referring Provider
National Provider ID
SBR-Other Subscriber
Information
2320 SBR09 Claim Filing
Indicator Code
Please ensure to
use the correct
indicator code(s)
when billing VI
Medicaid as a
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Loop Name Loop
ID
Field
Position/
Segment
Data Element
Name/Page
Number from
Implementation
Guide
Valid Values
And/or
Comments
A B C D E
secondary or
tertiary payer.
Do not send ‘MC’ in
this
Position/Segment
for secondary or
tertiary claims.
Valid values are;
‘11’ – Other
NonFederal
Programs
‘12’ – Preferred
Provider
Organization
(PPO)
‘13’ – Point of
Service (POS)
14 – Exclusive
Provider
Organization
(EPO) ‘15’ – Indemnity
Insurance
‘16’ – Health
Maintenance
Organization
(HMO) Medicare
Risk
‘17’ – Dental
Maintenance
Organization
‘AM’ – Automobile
Medical
‘BL’ – Blue Cross/
Blue Shield
‘CH’ – Champus
‘CI’ – Commercial
Insurance Co
‘DS’ – Disability
‘FI’ – Federal
Employees
Program
‘HM’ – Health
Maintenance
Organization
‘LM’ – Liability
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Loop Name Loop
ID
Field
Position/
Segment
Data Element
Name/Page
Number from
Implementation
Guide
Valid Values
And/or
Comments
A B C D E
Medical
‘MA’ – Medicare Part A
‘MB’ – Medicare
Part B
‘OF’ – Other
Federal Program
‘TV’ – Title V
‘VA’ – Veterans
Affairs Plan
‘WC’ – Workers’
Compensation
health Claim
‘ZZ’ – Mutually
Defined
Institutional Service Line 2400 SV202 Composite
Medical
Procedure
Identifier
Required for all
Outpatient claims
Institutional Service Line 2400 SV207 Monetary Amount
Line Item Denied
Charge or
NonCovered
Charge Amount
Line Adjustment 2430 CAS01 Claim Adjustment
Group Code
‘CR’ Correction and
Reversals
‘CO’ ‘OA’ ‘PI’ ‘PR’
Line Adjustment 2430 CAS02 Claim Adjustment
Reason Code
For adjustment
reason codes see
http://wpc-edi.com
Line Adjustment 2430 CAS03 Monetary Amount
Adjusted Amount
Line Level
Line Adjustment 2430 CAS04 Quantity/Adjusted
Units – Line
Level
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837 DENTAL TRANSACTION COMPANION GUIDE
The 837 Institutional Versions used in creating the guide.
Health Care Claim: Dental 005010X224 May 2006
Health Care Claim: Dental 005010X224A1 October 2007
Health Care Claim: Dental 005010X224A2 June 2010
Loop Name Loop ID Field
Position/
Segment
Data Element
Name/Page
Number from
Implementation
Guide
Valid Values
And/or
Comments
A B C D E
Version/Release/
Industry
Identifier Code
GS08 Identification
Code
005010X224A2
Subscriber
Hierarchical
Level
2000B HL04 Hierarchical
Level
‘0’
No subordinate HL
Segment in the
Hierarchical
Structure
Subscriber
Hierarchical
Level
2000B SBR09 Claim Filing
Indicator Code
“MC” Medicaid
Subscriber
Name
2010BA NM102 Entity Type
Qualifier
“1” Person
Subscriber
Name
2010BA NM108 Identification
Code Qualifier
“MI” Member
Identification
Number
Subscriber
Name
2010BA NM109 Identification
Code
USVI Medicaid
10 digit
Recipient
Number
Payer Name 2010BB NM103 Name Last or
Organization
Name
VI_MMIS_4_DXCMS
Payer Name 2010BB NM108 Identification
Code Qualifier
“PI” Payer Identification
Payer Name 2010BB NM109 Identification
Code
VI_MMIS_4_DXCMS
Claim
Information
2300 CLM01 Claim Submitter’s
Patient Account
Patient Control Number
Claim
Information
2300 CLM11-1 Related Causes
Code
“AA” – Auto Accident
“OA” – Other Accident
Claim
Information
2300 CLM12 Special Program
Code
“01‟ EPSDT
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Loop Name Loop ID Field
Position/
Segment
Data Element
Name/Page
Number from
Implementation
Guide
Valid Values
And/or
Comments
A B C D E
Referral
Identification
2300 REF01 Reference
Identification
Qualifier
“G3” Prior
Authorization
Number
Referral
Identification
2300 REF02 Reference
Identification
Referral Number
Assigned Prior
Authorization
Number
SBR-Other
Subscriber
Information
2320 SBR09 Claim Filing
Indicator Code
Please ensure to use
the correct indicator
code(s) when
billing VI
Medicaid as a
secondary or
tertiary payer.
Do not send
‘MC’ in this
Position/
Segment for
secondary or tertiary
claims.
Valid values
are;
‘11’ – Other
Non-Federal
Programs
‘12’ – Preferred
Provider
Organization
(PPO)
‘13’ – Point of
Service (POS)
14 – Exclusive
Provider
Organization (EPO)
‘15’ –
Indemnity Insurance
‘16’ – Health
Maintenance
Organization
(HMO)
Medicare Risk
‘17’ – Dental
Maintenance
Organization
‘AM’ – Automobile
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Loop Name Loop ID Field
Position/
Segment
Data Element
Name/Page
Number from
Implementation
Guide
Valid Values
And/or
Comments
A B C D E
Medical
‘BL’ – Blue Cross/
Blue Shield
‘CH’ – Champus
‘CI’ – Commercial
Insurance Co
‘DS’ – Disability
‘FI’ – Federal
Employees Program
‘HM’ – Health
Maintenance
Organization
‘LM’ – Liability
Medical
‘MA’ – Medicare
Part A
‘MB’ – Medicare
Part B
‘OF’ – Other
Federal Program
‘TV’ – Title V
‘VA’ – Veterans
Affairs Plan
‘WC’ – Workers’
Compensation
health Claim
‘ZZ’ – Mutually
Defined
Other
Subscriber
2320 AMT02 Monetary
Amount Payer
Paid Amount
Other Insurance paid
Amount
Line Adjustment 2430 CAS01 Claim Adjustment
Group Code
‘CR’ Correction and
Reversals
‘CO’ ‘OA’ ‘PI’ ‘PR’
Line Adjustment 2430 CAS02 Claim Adjustment
Reason Code
For adjustment reason
codes see
http://wpc-edi.com
Line Adjustment 2430 CAS03 Monetary Amount
Adjusted Amount
Line Level
Line Adjustment 2430 CAS04 Quantity/Adjusted
Units – Line
Level
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ATYPICAL PROVIDERS
Atypical Providers (performing non-health care services) who will be permitted to bill using their
existing Medicaid ID numbers.
The EDI formatting location of Billing, Referring, and Rendering Provider Information is dependent
upon the situation being billed. Below are the circumstances and EDI billing locations of this
information.
Billing Provider Location
This is used when the Billing Provider is a servicing provider only and/or if the Billing Provider is the
same as the Pay-To Provider.
Loop Header Loop Reference Definition Values
Billing Provider Tax
Identification
2010AA REF01 Reference Identification
Qualifier
‘EI’ or
‘SY’
Billing Provider Tax
Identification
2010AA REF02 Billing Provider Additional
Identifier
Billing Provider
Secondary
Identification
2010BB REF01 Reference Identification
Qualifier
‘G2’
Billing Provider
Secondary
Identification
2010BB REF02 Billing Provider Additional
Identifier
Billing
Medicaid
Provider
Number
Rendering
Provider Name
2310B REF01 Reference Identification
Qualifier
‘G2’
Rendering
Provider Name
2310B REF02 Reference Identification
Rendering
Medicaid
Provider
Number
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ADDITIONAL PROVIDER INFORMATION
Attending Physician NPI Location
Required when the claim being billed is for an Inpatient Bill Type.
VI Medicaid does not require the use of NPI when billing the Attending Physician number. Therefore
the NPI “OR” Legacy ID may be submitted when billing the Attending Physician ID.
Loop 2310A
Loop Name Loop ID Field
Position/
Segment
Data Element Name/Page
Number from
Implementation Guide Valid Values
And/or
Comments
Attending Physician
Name
2310A NM108 Identification Code Qualifier ‘XX’
National
Provider ID
Attending Physician
Name
2310A NM109 Identification Code Attending
Physician
National
Provider ID
Or
Loop Name Loop ID Field
Position/
Segment
Data Element Name/Page
Number from
Implementation Guide Valid Values
And/or
Comments
Attending Physician
Secondary
Identification
2310A REF01 Reference Identification
Qualifier
‘G2’
Medicaid
Provider
Number
Attending Physician
Secondary ID
2310A REF02 Reference Identification
Medicaid
Provider
Number
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APPENDICES
Implementation Checklist
The Health PAS-OnLine web portal user guides contains all necessary steps for going live with DXC
Technology in submitting specified EDI transactions, and receiving EDI responses, including the
5010 837. It also covers the following categories:
Register for a Trading Partner ID
Test with DXC Technology
The user guides can be found at https://www.vimmis.com/User%20Guides/Forms/AllItems.aspx.
Transmission Examples
TA1 Interchange Acknowledgement
The TA1 interchange acknowledgement is used to verify the syntactical accuracy of the envelope of
the X12 interchange. The TA1 interchange will indicate that the file was successfully received, as
well as indicate what errors existed within the envelope segments of the received X12 file.
The structure of a TA1 interchange acknowledgement depends on the structure of the envelope of
the original EDI document. When the envelope of the EDI document does not contain an error then
the interchange acknowledgement will contain the ISA, TA1, and IEA segments. The TA1 segment
will have an Interchange Acknowledgement Code of ‘A’ (Accepted) followed by a three-digit code of
‘000’ which indicates that there were not any errors.
If the EDI document contains an error at the interchange level, such as in the Interchange Control
Header (ISA) segment or the Interchange control trailer (IEA), then the interchange
acknowledgement will also only contain the ISA, TA1, and IEA segments. The TA1 segment will
have an Interchange Acknowledgement Code of ‘R’ (Rejected) which will be followed by a three-
digit number that corresponds to one of the following codes:
Code Description
000 No error
001 The Interchange Control Number in the Header and Trailer Do Not Match. The Value
From the Header is Used in the Acknowledgment
002 This Standard as Noted in the Control Standards Identifier is Not Supported
003 This Version of the Controls is Not Supported
005 Invalid Interchange ID Qualifier for Sender
006 Invalid Interchange Sender ID
009 Unknown Interchange Receiver ID
010 Invalid Authorization Information Qualifier Value (ISA01 is not ‘00’ or ‘03’)
012 Invalid Security Information Qualifier Value
013 Invalid Security Information Value
018 Invalid Interchange Control Number Value
019 Invalid Acknowledgment Requested Value
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Code Description
020 Invalid Test Indicator Value
021 Invalid Number of Included Groups Value
023 Improper (Premature) End-of-File (Transmission)
024 Invalid Interchange Content (e.g., Invalid GS Segment)
025 Duplicate Interchange Control Number
999 Implementation Acknowledgement for Health Care Insurance
The ASC X12 999 transaction set is designed to report only on conformance against a Technical
Report Type 3line (TR3).
The 999 is not limited to only Implementation Guide (TR3) errors. It can report standard syntax
errors, as well as Implementation Guide (TR3) errors.
The 999 cannot be used for any application level validations.
The ASC X12 999 transaction set is designed to respond to one and only one functional group (i.e.
GS/GE), but will respond to all transaction sets (i.e. ST/SE) within that functional group.
This ASC X12 999 Implementation Acknowledgement cannot be used to respond to any
management transaction sets intended for acknowledgements, i.e. TS 997 and 999, or interchange
control segments related to acknowledgments, i.e. TA1 and TA3.
Each segment in a 999 functional acknowledgement plays a specific role in the transaction. For
example, the AK1 segment starts the acknowledgement of a functional group. Each AKx segment
has a separate set of associated error codes.
The 999 functional acknowledgements include, but are not limited to, the following required
segments:
ST segment—Transaction Set Header
AK1 - Functional Group Response Header
AK2 - Transaction Set Response Header
IK3 – Error Identification
CTX – Segment Context
CTX – Business Unit Identifier
IK4 – Implementation Data Element Note
CXT – Element Context
IK5 – Transaction set response trailer
AK9 - Functional Group Response Trailer
SE -Transaction Set Trailer
For additional information regarding the 999 transaction, see the Implementation
Acknowledgement Section of the ASC X12 Standards for EDI Technical Report Type 3 Technical
Report Type 3 line for the transaction you are submitting.
824 Application Advice
This transaction is not mandated by HIPAA, but will be used to report the results of data content
edits of transaction sets. It is designed to report rejections based on business rules such as invalid
diagnosis codes, invalid procedure codes, and invalid provider numbers. The 824 Application Advice
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does not replace the 999 or TA1 transactions and will only be generated by Health PAS if there are
errors within the transaction set.
The 824 acknowledgment is divided into two levels of segments: header and detail.
The header level contains general information, such as the transaction set control
reference number of the previously sent transaction, date, time, submitter, and receiver.
The detail level reports the results of an application system’s data content edits.
The 824 Application Advice includes, but is not limited to following segments and their roles:
Header Segments:
ST segment—Transaction Set Header
BGN segment—Beginning Segment
N1 segment—Submitter Name
N1 segment—Receiver Name
Detail Segments:
OTI segment—Original Transaction Identification
TED segment—Error or Informational Message Location
RED segment—Error or Informational Message
SE segment—Transaction Set Trailer
The Health PAS Application outputs the following errors in the TED segment of the 824 Application
Advice:
Code
TED01
Description
TED02
O Missing or Invalid Issuer Identification
P Missing or Invalid Item Quantity
Q Missing or Invalid Item Identification
U Missing or Unauthorized Transaction Type Code
006 Duplicate
007 Missing Data
008 Out of Range
009 Invalid Date
010 Total Out of Balance
011 Not Matching
012 Invalid Combination
024 Other Unlisted Reason
027 Customer Identification Number Does not Exist
815 Duplicate Batch
848 Incorrect Data
DTE Incorrect Date
DUP Duplicate Transaction
ICA Invalid Claim Amount
IID Invalid Identification Code
NAU Not Authorized
UCN Unknown Claim Number
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Business Rejection Report
Health PAS also produces a readable version of the 824 called the Business Rejection Report (BRR).
This report helps to facilitate the immediate correction and re-bill of claims rejected during HIPAA
validation.
Frequently Asked Questions
This appendix contains a compilation of questions and answers relative to DXC Technology and its
providers. Typical question would involve a discussion about code sets and their effective dates.
See http://www.vimmis.com for answers to frequently asked questions.
Change Summary
The companion guide was updated to provide addition business scenario information for copayment
on the transmission response file.
Version Date Author Action/Summary
1.0 11/01/2012 USVI EDI Created to reflect 5010
1.1 02/06/2013 M. Searcy QA Review
1.2 11/30/2018 K. Banik DXC Rebranding
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Version Date Author Action/Summary
1.3 12/03/2018 Kim Stoudenmire QA of DXC Rebranding
1.4 05/01/2019 Katie Banik Per CR 2468, Updated Receiver ID
from VI_MMIS_4MOLINA to VI_MMIS_4_DXCMS
Updated TRANSACTION SPECIFIC INFORMATION
1.5 05/22/2019 Kim Stoudenmire QA review of updates for CR2468