837 I 5010A2 Conversion Business Impacts...subscriber or is considered to be the subscriber and is...

837 I 5010A2 Conversion Business Impacts

Title Business impacts in conversion of the 837I transaction to 5010A2

5010A2 Transaction Identifier 005010X223A2

Prepared By

Michael Stevens

Date December 18, 2008

Ingenix Confidential: Unauthorized access, copying, replication, and distribution is prohibited. This document must not be copied in whole or part by

any means, without the written authorization of Ingenix.

of 137

Table of Contents

Table of Contents ............................................................................................................................................2 Description......................................................................................................................................................4 General............................................................................................................................................................4 Conventions ....................................................................................................................................................4 Front Matter and Transaction Usage Changes ................................................................................................5

Coordination of Benefits Changes...............................................................................................................5 Provider Identification Changes..................................................................................................................5 Billing/Pay-to Provider Loop Changes .......................................................................................................5 Subscriber/Dependent Loop Usage Changes ..............................................................................................6 Loop and Segment changes from 4010A1 to 5010 .....................................................................................7

Loops deleted from the 4010A1 standard ...............................................................................................7 Loops added in the 5010 standard...........................................................................................................7 Loops moved in the 5010 Standard.........................................................................................................7 Segments deleted from the 4010A1 standard ..........................................................................................8 Segments added in the 5010 standard .....................................................................................................9

Data element changes with business impacts. ...............................................................................................10 Interchange Header Changes.....................................................................................................................10 Transaction Header Changes.....................................................................................................................10 Loop 1000A Submitter Name Changes.....................................................................................................11 Loop 1000B Receiver Name Changes ......................................................................................................12 Loop 2000A Billing Provider Hierarchical Level .....................................................................................12 Loop 2010AA Billing Provider Name ......................................................................................................12 Loop 2010AB Pay-to Address Name........................................................................................................17 Loop 2010AC Pay-to Plan Name..............................................................................................................18 Loop 2000B Subscriber Loop Hierarchical Changes................................................................................22 Loop 2010BA Subscriber Name ...............................................................................................................24 Loop 2010BB Credit/Debit Card Holder (Deleted in 5010) .....................................................................26 Loop 2010BB Payer Name (Moved in 5010) ...........................................................................................26 Loop 2010BD Responsible Party (Deleted in 5010).................................................................................29 Loop 2000C Hierarchical Level................................................................................................................30 Loop 2010CA Patient Name .....................................................................................................................32 Loop 2300 Claim Information...................................................................................................................33 Loop 2305 Home Health Care Plan Information (Deleted in 5010) .........................................................60

of 137

Loop 2310A Attending Provider...............................................................................................................61 Loop 2310B Operating Physician Name...................................................................................................64 Loop 2310C Other Provider (Deleted in 5010).........................................................................................67 Loop 2310C Other Operating Physician Loop (New in 5010)..................................................................68 Loop 2310D Rendering Provider Loop (New in 5010).............................................................................71 Loop 2310E Service Facility Location......................................................................................................74 Loop 2310F Referring Provider Loop (New in 5010)...............................................................................78 Loop 2320 Other Subscriber Information .................................................................................................81 Loop 2330A Other Subscriber Name........................................................................................................91 Loop 2330B Other Payer Name................................................................................................................92 Loop 2330C Other Payer Patient Identification (Deleted in 5010) ...........................................................95 Loop 2330C Other Payer Attending Provider (Loop 2330D in 4010) ......................................................96 Loop 2330D Other Payer Operating Physician (Loop 2330E in 4010).....................................................98 Loop 2330E Other Payer Other Operating Physician (Loop 2330F in 4010) .........................................100 Loop 2330F Other Payer Service Facility (Loop 2330H in 4010) ..........................................................102 Loop 2330G Other Payer Rendering Provider (New in 5010) ................................................................103 Loop 2330H Other Payer Referring Provider (New in 5010) .................................................................104 Loop 2330I Other Payer Billing Provider (New in 5010) .......................................................................106 Loop 2400 Service Line ..........................................................................................................................107 Loop 2410 Drug Identification................................................................................................................116 Loop 2420A Attending Physician Name (Deleted in 5010)....................................................................117 Loop 2420A Operating Physician Name (Loop 2420B in 4010) ............................................................118 Loop 2420B Other Operating Physician Name (New in 5010)...............................................................121 Loop 2420C Other Provider Name (Deleted in 5010) ............................................................................124 Loop 2420C Rendering Provider Name (New in 5010)..........................................................................125 Loop 2420D Referring Provider Name (New in 5010)...........................................................................128 Loop 2430 Line Adjudication Information .............................................................................................131 Interchange Trailer Changes ...................................................................................................................133

Appendices..................................................................................................................................................134 Change Log .............................................................................................................................................134

of 137

Description

This document provides an assessment of the business impacts of the conversion from the 4010A1 to 5010 standard of the 837I transaction set.

It looks at the Front Matter changes between the 4010A1 Implementation Guide and the 5010 Technical Report 3 (TR3) documents for the 837I.

It also looks at code, qualifier and usage changes within the 5010 837I transactions.

General The 5010 HIPAA implementation renames the 4010 implementation guides to ‘Technical Report 3’ documents. This document will refer to the 5010

implementation standards as TR3’s.

Conventions Loops, segments, and elements impacted by the conversion from 4010A1 to 5010 are presented in this document in table format.

The tables show loop, segment, and element usage changes specific to the 837I transaction, and details the changes between the 4010A1 and 5010 standards.

Text highlighted in yellow shows loops, segments, elements and values deleted from the 4010A1 to 5010 standard

Text highlighted in light blue shows loops, segments, elements and values added in the 5010 standard.

of 137

Front Matter and Transaction Usage Changes There were significant changes to section 1 of the TR3 that change the business usage rules for the 837I transaction. (Section 1.3 of the 4010A1 IG, Section

1.4 of the 5010 TR3).

Coordination of Benefits Changes The 5010 implementation of the 837I significantly enhances handling of Coordination of Benefit claims. These changes are designed to minimize manual

intervention and the use of paper supporting documentation. Support for electronic COB is based on the coordinated use of the 837 and 835 transactions.

Section 1.4.1 of the TR3 for the 837I contains a detailed explanation of the COB changes to the transaction.

Provider Identification Changes In the 5010 standard, NPI is the only valid primary identifier for a provider. In provider loops, the provider identification qualifier (NM108) is restricted to the

value ‘XX’.

In order to support atypical providers, the NM108/NM109 elements are now, when used, situational elements in any provider loop. These elements will be

omitted for providers that do not qualify for an NPI (Atypical providers).

The usage rule for NM108/NM109 elements in provider loops is as follows:

SITUATIONAL RULE: Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter. OR Required for providers prior to the mandated HIPAA NPI implementation date when the provider has received an NPI and the submitter has the capability to send it. If not required by this implementation guide, do not send.

Billing/Pay-to Provider Loop Changes In the 5010 standard, Pay-to Provider no longer exists as an entity distinct from Billing Provider.

In the 5010 standard, the pay-to loop (Loop 2010AB) only contains a pay-to address when different from the billing provider address. It does not contain any

provider identification.

of 137

Subscriber/Dependent Loop Usage Changes The rules for usage of the dependent/patient loop (2000C) have changed in the 5010 standard. The rules for identifying member and dependent are defined on

page 114 of the TR3 as follows:

1. If a patient can be uniquely identified to the destination payer in Loop ID-2010BB by a unique Member Identification Number, then the patient is the

subscriber or is considered to be the subscriber and is identified at this level, and the patient HL in Loop ID-2000C is not used.

2. If the patient is not the subscriber and cannot be identified to the destination payer by a unique Member Identification Number or it is not known to the

sender if the Member Identification number is unique, both this HL and the patient HL in Loop ID- 2000C are required.

of 137

Loop and Segment changes from 4010A1 to 5010 This section provides an overview of the loop and segment changes between the 4010A1 and 5010 versions of the 837I. A detailed listing of segment/element

impacts for each of these changes is listed in the next section of this document.

Loops deleted from the 4010A1 standard

Loop Loop Name

2010BB Credit/Debit Card Account Holder Name

2010BD Responsible Party Name

2310C Other Provider Name

2330C Other Payer Patient Information

2420A Attending Physician Name

Loops added in the 5010 standard

Loop Loop Name

2010AC Pay-to Plan

2310C Other Operating Physician

2310D Rendering Provider

2310F Referring Provider

2330G Other Payer Rendering Provider

2330H Other Payer Referring Provider

2330I Other Payer Billing Provider

2420C Rendering Provider Name

2420D Referring Provider Name

Loops moved in the 5010 Standard

Loop Name 4010A1 Loop 5010 Loop

Payer Name 2010BC 2010BB

Other Payer Attending Provider 2330D 2330C

Other Payer Operating Provider 2330E 2330D

Other Payer Other Operating Provider 2330F 2330E

Other Payer Service Facility Location 2330H 2330F

Operating Physician Name 2420B 2420A

Other Operating Physician Name 2420C 2420B

of 137

Segments deleted from the 4010A1 standard

This is a list of 4010A1 segments deleted from the 5010 standard where the loops these segments were used in were not deleted

Loop Segment Segment Name

Transaction

Header

REF Transmission Type Identification

2010AA REF Credit/Debit Card Billing Information

2010AB REF Pay-to Provider Secondary Identification

2010CA REF Patient Secondary Identification Segment

2300 AMT Payer Estimated Amount Due

2300 AMT Patient Amount Due

2300 AMT Credit/Debit Card Maximum Amount

2300 REF Document Identification Code

2300 CR6 Home Health Care Information

2300 CRC Home Health Functional Limitations

2300 CRC Home Health Activities Permitted

2300 CRC Home Health Mental Status

2300 HI Principal, Admitting, E Code, and Patient Reason For Visit

Diagnosis Information (This segment has been split into 4 separate

segments in the 5010 standard).

2300 QTY Claim Quantity

2305 CR7 Home Health Care Plan Information

2305 HSD Health Care Services Delivery

2320 AMT COB Total Submitted Charges

2320 AMT COB DRG Outlier Amount

2320 AMT COB Total Medicare Paid Amount

2320 AMT COB Medicare Paid Amount – 100%

2320 AMT COB Medicare Paid Amount – 80%

2320 AMT COB Medicare A Trust Fund Paid Amount

2320 AMT COB Medicare B Trust Fund Paid Amount

2320 AMT COB Total Non-Covered Amount

2320 AMT COB Total Denied Amount

2320 DMG Other Subscriber Demographic Information

2400 DTP Assessment Date

of 137

Segments added in the 5010A2 standard

This is a list of segments added to existing loops in the 5010 standard.

Loop Segment Segment Name

2010BB REF Billing Provider Secondary Identification (was loop 2010BC in

4010A1)

2010CA REF Property and Casualty Patient Identifier

2300 DTP Date – Repricer Received Date

2300 REF Auto Accident State

2300 CRC EPSDT Referral

2300 HI Principal Diagnosis (Restructured from 4010A1)

2300 HI Admitting Diagnosis (Restructured from 4010A1)

2300 HI Patient’s Reason for Visit (Restructured from 4010A1)

2300 HI External Cause of Injury (Restructured from 4010A1)

2300 QTY Claim Quantity

2320 AMT Remaining Patient Liability

2330B REF Other Payer Claim Adjustment Indicator

2330B REF Other Payer Claim Control Number

2400 REF Line Item Control Number

2400 REF Repriced Line Item Reference Number

2400 REF Adjusted Repriced Line Item Reference Number

2400 NTE Third Party Organization Notes

2430 AMT Remaining Patient Liability

of 137

Data element changes with business impacts. This section lists all data elements that have changed, and analyzes business impacts for those changes.

Interchange Header Changes

Loop Segment /

Element Element Name

4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

N/A ISA Segment

Repeat: Not specified

Segment Repeat: 1 Segment Repeat deleted

Change in Segment Repeat

N/A ISA11

4010: Interchange Control Version Number 5010 : Repetition Separator

U Defined between trading partners

This element is a delimiter in the 5010 standard, and must not occur in data.

N/A ISA12 Interchange Control Version Number

00401 00501

N/A GS Segment

Repeat: Not specified

Segment Repeat: 1 Segment Repeat deleted

Change in Segment Repeat

N/A GS08 Version Release / Industry Code Identifier

004010X096A1 005010X223A1 005010X223A2

Transaction Header Changes

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

N/A ST03 Implementation Convention Reference

005010X223A1 005010X223A2 New element in 5010

N/A BHT03 Reference Identification Length: 30 Length: 50 Length increase from 30-50

N/A BHT06 Transaction Type Code

CH:

Chargeable

RP: Reporting

31: Subrogation Demand

CH: Chargeable RP: Reporting

TR3 usage rules for ‘31’ – Subrogation Demand:

The subrogation demand code is only for use by

state Medicaid agencies performing post payment

recovery claiming with willing trading partners.

NOTE: At the time of this writing, Subrogation

Demand is not a HIPAA mandated use of the 837

transaction.

N/A REF Transmission Type Identification Segment

Deleted This segment is not used in the 5010 standard

of 137

N/A REF01 Transmission Type Identification Reference Identification Qualifier

Element Deleted 87:

N/A REF02 Transmission Type Identification Element Deleted

Loop 1000A Submitter Name Changes

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values and

Descriptions

5010A2

Valid Values

and

Description

s

Notes

1000A NM103 Submitter Name Name Last or organization Name

Length: 35 Length: 60 Length increase from 35-60

1000A NM104 Submitter Name Name First

Length: 25 Length: 35

Length increase from 25-35 New TR3 rule:

SITUATIONAL RULE: Required when NM102 = 1 (person)

and the person has a first name. If not required by

this implementation guide, do not send.

Functionally, this element is no longer required when NM102 is ‘1’ – Person.

1000A PER03

Submitter EDI Contact Information Communications Number Qualifier

ED: Electronic Data Interchange Access Number

EM: Electronic Mail

FX: Facsimile TE: Telephone

EM: Electronic Mail FX: Facsimile TE: Telephone

Code Deleted

1000A PER05 PER07

Submitter EDI Contact Information Communications Number Qualifier

ED: Electronic Data Interchange Access Number

EM: Electronic Mail

EX: Telephone Extension

FX: Facsimile TE: Telephone

EM: Electronic Mail EX: Telephone

Extension FX: Facsimile TE: Telephone

Code Deleted

1000A PER04 PER06 PER08

Submitter EDI Contact Information Communication Number

Length: 1 - 80 Length: 1 - 256 Maximum length increase from 80 – 256

of 137

Loop 1000B Receiver Name Changes

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

1000B NM103 Receiver Name Name Last or organization Name


Loop 2000A Billing Provider Hierarchical Level

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2000A PRV01 Billing/Pay-to Specialty Information Provider Code

BI: Billing PT: Pay-To

BI: Billing Code Deleted

2000A PRV02 Billing/Pay-to Specialty Information Reference Identification Qualifier

ZZ: Mutually Defined

PXC: Health Care Provider Taxonomy Code

Qualifier change only, Usage intent to indicate Taxonomy code has not changed.

2000A PRV03 Billing/Pay-to Specialty Information Provider Taxonomy Code

Length: 30 Length: 50 Valid Taxonomy code is 10 bytes in length, this change should have no functional impact.

Loop 2010AA Billing Provider Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010AA NM103 Billing Provider Name Name Last or organization Name


of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010AA NM108 Billing Provider Name Identification Code Qualifier

Usage: Required 24: Employer’s

Identification Number

34: Social Security Number

XX: Health Care Financing Administration National Provider Identifier

Usage: Situational XX: Health Care

Financing Administration National Provider Identifier

Usage changed from required to situational: TR3 rule:

SITUATIONAL RULE: Required for providers in the

United States or its territories on or after the

mandated HIPAA National Provider Identifier (NPI)

implementation date when the provider is eligible

to receive an NPI.

OR

Required for providers not in the United States or

its territories on or after the mandated HIPAA

National Provider Identifier (NPI) implementation

date when the provider has received an NPI.

OR

Required for providers prior to the mandated NPI

implementation date when the provider has

received an NPI and the submitter has the

capability to send it.

If not required by this implementation guide, do not

send.

With the 5010 implementation, this qualifier now supports only the identifier for NPI

2010AA NM109 Billing Provider Name Billing Provider Identifier

Usage: Required Usage: Situational

Usage changed from Required to Situational TR3 rule:

SITUATIONAL RULE: Required for providers in the

United States or its territories on or after the

mandated HIPAA National Provider Identifier (NPI)

implementation date when the provider is eligible

to receive an NPI.

OR

Required for providers not in the United States or

its territories on or after the mandated HIPAA

National Provider Identifier (NPI) implementation

date when the provider has received an NPI.

OR

Required for providers prior to the mandated NPI

implementation date when the provider has

received an NPI and the submitter has the

capability to send it.

If not required by this implementation guide, do not

send. In 4010A1, could be Tax ID, SSN, or NPI. In 5010, must be NPI

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010AA N402 Billing Provider Address State or Province code


Segment N4 now supports international addresses. Usage changed from Required to Situational TR3 Rule:

SITUATIONAL RULE: Required when address is in the

United States of America, including its territories,

or Canada. If not required by this implementation

guide, do not send.

2010AA N403 Billing Provider Address Postal code


Usage changed from Required to Situational TR3 Rule:

SITUATIONAL RULE: Required when the address is in

the United States of America, including its

territories, or Canada, or when a postal code exists

for the country in N404. If not required by this

implementation guide, do not send.

2010AA N407 Billing Provider Address Country Subdivision Code

New Element in 5010

Usage: Situational TR3 Rule:

SITUATIONAL RULE: Required when the address is not

in the United States of America, including its

territories, or Canada, and the country in N404 has

administrative subdivisions such as but not limited

to states, provinces, cantons, etc. If not required by


2010AA REF Billing Provider Secondary Identification Segment

Usage: Situational

Usage: Required Name Change: BILLING

PROVIDER TAX IDENTIFICATION

Usage change from situational to required Billing Provider Tax ID or SSN is now required in this segment

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010AA REF01

Billing Provider Secondary Identification Reference Identification Qualifier

0B: State License Number

1A: Blue Cross Provider Number

1B: Blue Shield Provider Number

1C: Medicare Provider Number

1D: Medicaid Provider Number

1G: Provider UPIN Number

1H: CHAMPUS Identification Number

1J: Facility ID Number

B3: Preferred Provider Organization Number

BQ: Health Maintenance Organization Code Number

EI: Employer’s Identification Number

FH: Clinic Number

G2: Provider Commercial Number

G5: Provider Site Number

LU: Location Number

SY: Social Security Number

X5: State Industrial Accident Provider

EI: Employer’s


Qualifier now restricted to only Tax ID

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010AA REF02 Billing Provider Additional Identifier

Length: 1 - 30 Length: 1 - 50

Maximum length change from 30 to 50 In 5010, valid value restricted to Tax ID or SSN. Length change should have no business impact in this loop.

2010AA REF Credit/Debit Card Billing Information

Segment Deleted

This segment is not used in the 5010 standard Credit/Debit card information is not included in any loop in the 5010 standard

2010AA REF01

Credit/Debit Card Billing Information Reference Identification Qualifier

Element Deleted

2010AA REF02 Credit/Debit Card Billing Information

Element Deleted

2010AA PER02 Billing Provider Contact Name Usage: Required Usage: Situational


SITUATIONAL RULE: Required in the first iteration

of the Billing Provider Contact Information

segment. If not required by this implementation

guide, do not send.

2010AA PER04 PER06 PER08

Billing Provider Contact Information Communication Number


of 137

Loop 2010AB Pay-to Address Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010AB NM1 Pay-to Provider Name

Usage for the pay-to provider loop has changed significantly from 4010A1 to 5010. Pay-to provider no longer exists as an entity distinct from billing provider. In the 5010 standard, the pay-to loop only contains a pay-to address when different from the billing provider address. It does not contain any provider identification. TR3 rule:

Situational Rule: Required when the address for

payment is different than that of the Billing

Provider. If not required by this implementation

guide, do not send.

TR3 Notes: 1. The purpose of Loop ID-2010AB has

changed from previous versions. Loop ID-2010AB

only contains address information when different

from the Billing Provider Address. There are no

applicable identifiers for Pay-To Address

information.

2010AB NM103 Pay-to Provider Name Last Name

Element Deleted

2010AB NM108 Pay-to Provider Name Identification Code Qualifier

Element Deleted

2010AB NM109 Pay-to Provider Name Identifier

Element Deleted

2010AB N402 Pay-to Provider Address State or Province code






guide, do not send.

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010AB N403 Pay-to Provider Address Postal code








2010AB N407 Pay-to Provider Address Country Subdivision Code

New Element in 5010








2010AB REF Pay-to Provider Secondary Identification

Segment Deleted

This segment is not used in the 5010 standard Pay-to provider no longer exists as an entity distinct from billing provider. Pay-to provider loop contains pay-to address only.

2010AB REF01

Pay-to Provider Secondary Identification Reference Identification Qualifier

Element Deleted

2010AB REF02 Pay-to Provider Secondary Identification

Element Deleted

Loop 2010AC Pay-to Plan Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010AC Pay-to Plan Name New Loop

TR3 Rule for loop usage:

Usage: SITUATIONAL

Situational Rule: Required when willing trading

partners agree to use this implementation for their

subrogation payment requests.

This loop may only be used when BHT06 = 31

2010AC NM1 Pay-to Plan Name New Segment Usage: Required when loop 2010AC is used

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010AC NM101 Pay-to Plan Name Entity Identifier Code

New Element PE: Payee

Usage: Required TR3 Rule:

PE is used to indicate the subrogated payee.

2010AC NM102 Pay-to Plan Name Entity Type Qualifier

New Element 2: Non-Person Entity

Usage: Required

2010AC NM103 Pay-to Plan Name Pay-to Plan Organization Name

New Element Usage: Required Length: 1 – 60

2010AC NM108 Pay-to Plan Name Identification Code Qualifier

New Element PI: Payor Identification XV: Centers for Medicare and Medicaid Services PlanID

Usage: Required TR3 Rule:

On or after the mandated implementation date for

the HIPAA National Plan Identifier (National Plan

ID), XV must be sent. Prior to the mandated

implementation date and prior to any phasein

period identified by Federal regulation, PI must be

sent. If a phase-in period is designated, PI must be

sent unless:

1. Both the sender and receiver agree to use the

National Plan ID,

2. The receiver has a National Plan ID, and

3. The sender has the capability to send the

National Plan ID.

If all of the above conditions are true, XV must be

sent. In this case the Payer Identification Number

that would have been sent using qualifier PI can be

sent in the corresponding REF segment using

qualifier 2U.

2010AC NM109 Pay-to Plan Name Identification Code

New Element Usage: Required Length: 1-50

2010AC N3 Pay-to Plan Address New Segment Usage: Required when loop 2010AC is used

2010AC N301 Pay-to Plan Address Address Line 1

New Element Usage: Required Length: 1-55

2010AC N302 Pay-to Plan Address Address Line 2

New element Usage: Situational Length: 1-55

2010AC N4 Pay-to Plan City/State/Zip Code New Segment Usage: Required when loop 2010AC is used

2010AC N401 Pay-to Plan City New Element Usage: Required Length: 2-30

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010AC N402 Pay-to Plan Address State or Province code

New Element

Segment N4 now supports international addresses. Changed from required to Situational TR3 Rule:




guide, do not send.

2010AC N403 Pay-to Plan Address Postal code

New Element







2010AC N404 Pay-to Plan Address Country Code

New Element


SITUATIONAL RULE: Required when the address is

outside the United States of America. If not

required by this implementation guide, do not

send.

2010AC N407 Pay-to Plan Address Country Subdivision Code

New Element








2010AC REF Pay-to Plan Secondary Identification

New Segment


Required prior to the mandated implementation

date for the HIPAA National Plan Identifier when an

additional identification number to that provided in

the NM109 of this loop is necessary for the claim

processor to identify the entity. If not required by


of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010AC REF01

Pay-to Plan Secondary Identification Reference Identification Qualifier

New Element 2U: Payer


FY: Claim Office Number

NF: National Association of Insurance Commissioners (NAIC) Code

Usage: Required TR3 rule for qualifier ‘2U’:

This code is only allowed when the National Plan

Identifier is reported in NM109 of this loop.

2010AC REF02

Pay-to Plan Secondary Identification Reference Identifier

New Element Length: 1-50

Usage: Required

2010AC REF Pay-to Plan Tax identification

New Segment Usage: Required when loop 2010AC is used

2010AC REF01

Pay-to Plan Tax identification Reference Identification Qualifier

New Element EI: Employer’s


Usage: Required

2010AC REF02 Pay-to Plan Tax identification


Usage: Required

of 137

Loop 2000B Subscriber Loop Hierarchical Changes

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2000B SBR01 Subscriber Information Payer Responsibility Sequence Number code

P: Primary S:

Secondary

T: Tertiary

A: Payer Responsibility Four

B: Payer Responsibility Five

C: Payer Responsibility Six

D: Payer Responsibility Seven

E: Payer Responsibility Eight

F: Payer Responsibility Nine

G: Payer Responsibility Ten

H: Payer Responsibility Eleven

P: Primary S: Secondary T: Tertiary U: Unknown

Codes Added

2000B SBR03 Insured Group or Policy Number Length: 1 - 30 Length: 1 - 50 Maximum Length Increase from 30 – 50

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2000B SBR09 Subscriber Information Claim Filing Indicator code

09: Self-pay 10: Central

Certification

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

AM: Automobile Medical

BL: Blue Cross/Blue Shield

CH: Champus CI:

Commercial Insurance Co.

DS: Disability HM: Health

Maintenance Organization

LI: Liability LM: Liability

Medical MA: Medicare

Part A MB: Medicare

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

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

Medical MA: Medicare Part

A MB: Medicare Part

B MC: Medicaid OF: Other Federal

Codes Deleted Codes Added

of 137

Loop 2010BA Subscriber Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010BA NM103 Subscriber Name Name Last or organization Name

Length: 1 - 35 Length: 1- 60 Maximum length increase from 35 – 60

2010BA NM104 Subscriber Name Name First


Maximum length increase from 25 – 35 New TR3 rule:





2010BA NM108 Subscriber Name Identification Code Qualifier

Usage: Situational

MI: Member

Identification

ZZ: Mutually Defined (HIPAA individual identifier)

Usage: Required MI: Member

Identification II: Standard

Unique Health Identifier for each Individual in the United States

Usage: Situational

Usage changed from Required to Situational in 5010A2. Situational Rule in 5010A2: Required when NM102 = 1 (person). If not required by this implementation guide, do not send.

2010BA NM109 Subscriber Name Subscriber Primary Identifier

Usage: Situational


Usage changed from Required to Situational in 5010A2. Situational Rule in 5010A2: Required when NM102 = 1 (person). If not required by this implementation guide, do not send.

2010BA N4 Subscriber City/State/Zip Code Usage: Required Usage: Situational

Usage changed from Required to Situational in 5010A2. Situational Rule in 5010A2: Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send.

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010BA N402 Subscriber City/State/Zip Code State or Province code






guide, do not send.

2010BA N403 Subscriber City/State/Zip Code Postal code








2010BA N407 Subscriber City/State/Zip Code Country Subdivision Code

New Element in 5010








2010BA REF01 Subscriber Secondary Identification Reference Identification Qualifier

1W: Member Identification Number

23: Client Number

IG: Insurance Policy Number

SY: Social Security Number

SY: Social Security

Number

Codes Deleted

2010BA REF02

Subscriber Secondary Identification Subscriber Supplemental Identifier


Maximum Length Increase from 30 – 50 Now restricted to SSN only, length change should have no impact

2010BA REF02 Property and Casualty Claim Number

Length: 1 - 30 Length: 1 - 50 Maximum Length Increase from 30 – 50

of 137

Loop 2010BB Credit/Debit Card Holder (Deleted in 5010)

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Description

s

Notes

2010BB Credit/Debit Card Holder Loop Deleted

2010BB NM1 Credit/Debit Card Holder Name Segment

Deleted

2010BB NM101 Credit/Debit Card Holder Name Entity Identifier Code

Element Deleted

2010BB NM102 Credit/Debit Card Holder Name Entity Type Qualifier

Element Deleted

2010BB NM103 Credit/Debit Card Holder Name Last Name or Organization Name

Element Deleted

2010BB NM104 Credit/Debit Card Holder Name First Name

Element Deleted

2010BB NM105 Credit/Debit Card Holder Name Middle Name

Element Deleted

2010BB NM107 Credit/Debit Card Holder Name Name Suffix

Element Deleted

2010BB NM108 Credit/Debit Card Holder Name Identification Code Qualifier

Element Deleted

2010BB NM109 Credit/Debit Card Holder Name Credit or Debit Card Number

Element Deleted

2010BB REF Credit/Debit Card Information Element Deleted

2010BB REF01 Credit/Debit Card Information Information Code Qualifier

Element Deleted

2010BB REF02 Credit/Debit Card Information Authorization Number

Element Deleted

Loop 2010BB Payer Name (Moved in 5010)

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Description

s

Notes

2010BB Payer Name 4010A1 Loop:

2010BC

5010A1 Loop:

2010BB Loop moved in 5010

2010BB NM103 Payer Name Organization Name

Length: 1 - 35 Length: 1 - 60 Maximum length increase from 35-60

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Description

s

Notes

2010BB N4 Payer City/State/Zip Code Segment

Usage: Situational


Usage changed from Required to Situational in 5010A2. Situational Rule in 5010A2: Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send.

2010BB N402 Payer City/State/Zip Code State or Province code




United States of America, including its territories, or

Canada. If not required by this implementation

guide, do not send.

2010BB N403 Payer City/State/Zip Code Postal code



SITUATIONAL RULE: Required when the address is in the


Canada, or when a postal code exists for the

country in N404. If not required by this


2010BB N407 Payer City/State/Zip Code Country Subdivision Code

New Element in 5010








of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Description

s

Notes

2010BB REF01 Payer Secondary Identification Reference Identification Qualifier

2U: Payer Identification Number

FY: Claim

Office Number


TJ: Federal Taxpayer’s Identification Number

2U: Payer Identification Number

EI: Employer’s Identification Number

FY: Claim Office Number


Code Added Code Deleted

2010BB REF02 Payer Additional Identifier Length: 1 - 30 Length: 1 - 50 Maximum length increase from 30 – 50

2010BB REF Billing Provider Secondary Identification

New Segment

New Segment Usage: Situational TR3 Rule:

Situational Rule: Required prior to the mandated

NPI Implementation Date when an additional

identification number is necessary for the receiver

to identify the provider.

OR

Required on or after the mandated NPI

Implementation Date when NM109 in Loop 2010AA

is not used and an identification number other than

the NPI is necessary for the receiver to identify the

provider. If not required by this implementation

guide, do not send.

2010BB REF01 Billing Provider Secondary Identification Reference Identification Qualifier

New Element G2: Provider

Commercial Number

LU: Location Number

Usage: Required TR3 Usage note for value ‘G2’

This code designates a proprietary provider number

for the destination payer identified in the Payer

Name loop, Loop ID-2010BB, associated with this

claim. This is to be used by all payers including:

Medicare, Medicaid, Blue Cross, etc.

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Description

s

Notes

2010BB REF02 Billing Provider Secondary Identifier

New Element Length: 1 - 50

Usage: Required

Loop 2010BD Responsible Party (Deleted in 5010)

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010BD Responsible Party Loop Deleted

2010BD NM1 Responsible Party Name Segment

Deleted

2010BD NM101 Responsible Party Name Entity Identifier Code

Element Deleted

2010BD NM102 Responsible Party Name Entity Type Qualifier

Element Deleted

2010BD NM103 Responsible Party Name Last Name or Organization Name

Element Deleted

2010BD NM104 Responsible Party Name First Name

Element Deleted

2010BD NM105 Responsible Party Name Middle Name

Element Deleted

2010BD NM107 Responsible Party Name Name Suffix

Element Deleted

2010BD N3 Responsible Party Address Segment

Deleted

2010BD N301 Responsible Party Address Address Line 1

Element Deleted

2010BD N302 Responsible Party Address Address Line 2

Element Deleted

2010BD N4 Responsible Party City/State/Zip Code

Segment Deleted

2010BD N401 Responsible Party City Element Deleted

2010BD N402 Responsible Party State Element Deleted

2010BD N403 Responsible Party Zip Code Element Deleted

2010BD N404 Responsible Party Country Code Element Deleted

of 137

Loop 2000C Hierarchical Level

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2000C PAT01 Patient Information Individual Relationship Code

01: Spouse 04:

Grandfather or Grandmother

05: Grandson or Granddaughter

07: Nephew or Niece

10: Foster Child

15: Ward 17: Stepson or

Stepdaughter

19: Child 20: Employee 21: Unknown 22:

Handicapped Dependent

23: Sponsored Dependent

24: Dependent of a Minor Dependent

29: Significant Other

32: Mother 33: Father 36:

Emancipated Minor

39: Organ Donor

40: Cadaver Donor

41: Injured Plaintiff

43: Child Where Insured Has No Financial Responsibility

01: Spouse 19: Child 20: Employee 21: Unknown 39: Organ Donor 40: Cadaver

Donor 53: Life Partner G8: Other

Relationship

Codes Deleted

of 137

Loop 2010CA Patient Name

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2010CA NM103 Patient Name Name Last or organization Name


2010CA NM104 Patient Name Name First

Length: 1 – 25 Length: 1 - 35

Maximum length increase from 25-35 New TR3 rule:





2010CA NM108 Patient Name Identification Code Qualifier

Element Deleted

2010CA NM109 Patient Name Patient Primary Identifier

Element Deleted

2010CA N402 Patient City/State/Zip Code State or Province code





Canada. If not required by this implementation

guide, do not send.

2010CA N403 Patient City/State/Zip Code Postal code



SITUATIONAL RULE: Required when the address is in the


Canada, or when a postal code exists for the

country in N404. If not required by this


of 137

2010CA N407 Patient City/State/Zip Code Country Subdivision Code

New Element in 5010


SITUATIONAL RULE: Required when the address is not in






2010CA REF Patient Secondary Identification Segment

Segment Deleted

2010CA REF01 Patient Secondary Identification Reference Identification Qualifier

Element Deleted

2010CA REF02 Patient Secondary Identification Patient Secondary Identifier

Element Deleted

2010CA REF02 Property and Casualty Claim Number


2010CA REF Property and Casualty Claim Patient Information

New Segment

Usage: Situational Situational Rule in 5010A1: Required when an identification number is needed by the receiver to identify the patient for Property and Casualty claims. If not required by this implementation guide, do not send.

2010CA REF01 Property and Casualty Claim Patient Information Reference Identification Qualifier

New Element 1W: Member Identification Number SY: Social Security Number

Usage: Required

2010CA REF02 Property and Casualty Claim Patient Information Reference Identification

Length: 1 – 50

Usage: Required

Loop 2300 Claim Information

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 CLM05-01

Claim Information Health Care Service Location Information

Place of Service Code

Place of Service Code

Code Source 235: The 4010A1 IG lists values for this element as a courtesy. Source of truth for valid values is “Place of Service Codes for Professional And Dental Claim’ listed at http://www.cms.hhs.gov/MedHCPCSGenInfo/Downloads/ Place_of_Service.pdf No functional differences in edit

2300 CLM06

Claim Information Yes/No Condition or Response Code

Usage: Required

Usage: Not Used Usage changed from Required to Not Used

2300 CLM07 Claim Information Medicare Assignment Code

A: Assigned C: Not

Assigned

A: Assigned B: Assignment

Accepted on Clinical Lab Services Only

C: Not Assigned

Code Added

2300 CLM08

Claim Information Benefits Assignment Certification Indicator

N: No Y: Yes

N: No W: Not Applicable Y: Yes

New Code TR3 usage notes for ‘W’

Use code ‘W’ when the patient refuses to assign

benefits.

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 CLM09 Claim Information Release of Information Code

A: Appropriate Release of Information on File at Health Care Service Provider or at Utilization Review Organization

I: Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

M: The Provider has Limited or Restricted Ability to Release Data Related to a Claim

N: No, Provider is Not Allowed to Release Data

O: On file at Payor or at Plan Sponsor

Y: Yes, Provider has a Signed Statement Permitting Release of Medical Billing

I: Informed

Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes

Y: Yes, Provider

has a Signed Statement Permitting Release of Medical Billing Data Related to a

Codes Deleted

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 CLM18

Claim Information Explanation of Benefits (EOB) Indicator

Element Deleted Usage:

Situational

Usage: Not Used

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 CLM20 Claim Information Delay Reason Code

1: Proof of Eligibility Unknown or Unavailable

2: Litigation 3

Authorization Delays

4: Delay in Certifying Provider

5: Delay in Supplying Billing Forms

6: Delay in Delivery of Custom-made Appliances

7: Third Party Processing Delay

8: Delay in Eligibility Determination

9: Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules

10:Administration Delay in the Prior Approval Process

11: Other

1: Proof of Eligibility Unknown or Unavailable

2: Litigation 3: Authorization

Delays 4: Delay in

Certifying Provider

5: Delay in Supplying Billing Forms

6: Delay in

Delivery of Custom-made Appliances

7: Third Party Processing Delay

8: Delay in Eligibility Determination

9: Original

Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules

10:

Administration Delay in the Prior Approval Process

11: Other 15: Natural

Disaster

Code Added

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 DTP02 Date – Statement Dates Date Time Qualifier

D8: Date Expressed in Format CCYYMMDD

RD8: Range of Dates Expressed in Format CCYYMMDDCCYYMMDD

RD8: Range of

Dates Expressed in Format CCYYMMDDCCYYMMDD

Code Added Statement Dates must be a date range in the 5010A1 standard. TR3 Usage note for value ‘RD8’

Use RD8 to indicate the from and through date of the

statement. When the statement is for a single date of

service, the from and through date are the same.

2300 DTP03 Date – Statement Dates

CCYYMMDD or CCYYMMDDCC

YYMMDD

CCYYMMDDCCYYMMDD

Statement Dates must be a date range in the 5010A1 standard.

2300 DTP02 Date – Admission Date/Hour Date Time Qualifier

DT: Date and

Time Expressed in Format CCYYMMDDHHMM

D8: Date Expressed in Format CCYYMMDD

DT: Date and Time Expressed in Format CCYYMMDDHHMM

Code Deleted Format expanded to support date as well as date/time

2300 DTP03 Date – Statement Dates

CCYYMMDDHH

MM

CCYYMMDD or CCYYMMDDHHM

M

Format expanded to support date as well as date/time

2300 DTP Date – Repricer Received Date New Segment

Usage: Situational TR3 Usage Rule:

Required when a repricer is passing the claim onto

the payer. If not required by this implementation

guide, do not send..

2300 DTP01 Date – Repricer Received Date Date Time Qualifier

New Element 050: Received

Usage: Required

2300 DTP02 Date – Repricer Received Date Date Time Period Format Qualifier

New Element D8: Date

Expressed in Format CCYYMMDD

Usage: Required

2300 CL1 Institutional Claim Code Usage:

Situational Usage: Required Segment usage changed from Situational to Required

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 CL101 Institutional Claim Code Admission Type Code

Usage: Situational Code Source 231: Admission Type Code

Usage: Required Code Source 231: Priority (Type) of Admission or Visit

Usage changed from Situational to Required in 5010A2. Code Source 231 changed from “Admission Type Code” to “Priority (Type) of Admission or Visit” in 5010A2 TR3 5010A2 Notes: The name of this code set was “Admission Type Code” at the time of publication. The owner, NUBC, has changed this to “Priority (Type) of Admission or Visit.”

2300 CL102 Institutional Claim Code Admission Source Code

Code Source 230: Admission Source Code

Code Source 230: Priority (Type) of Admission or Visit

Code Source 231 changed from “Admission Source Code” to ”Point of Origin for Admission or Visit” in 5010A2 TR3 5010A2 Notes: The name of this code set was “Admission Source Code” at the time of publication. The owner, NUBC, has changed this to “Point of Origin for Admission or Visit.”

2300 PWK01 Attachment Report Type Code

03: Report Justifying Treatment Beyond Utilization Guidelines

04: Drugs Administered

05: Treatment Diagnosis

06: Initial Assessment

07: Functional Goals

08: Plan of Treatment

09: Progress Report

10: Continued Treatment

11: Chemical Analysis

13: Certified Test Report

15: Justification for Admission

21: Recovery Plan

A3: Allergies/

Codes Added

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

AS: Admission

Summary B2:

Prescription

B3: Physician Order

B4: Referral Form

CT:

Certification

DA: Dental

Models DG: Diagnostic

Report DS: Discharge

Summary EB:

Explanation of Benefits (Coordination of

Sensitivities Document

A4: Autopsy Report

AM: Ambulance Certification

AS: Admission

Summary B2: Prescription B3: Physician

Order B4: Referral

Form BR: Benchmark

Testing Results

BS: Baseline BT: Blanket Test

Results CB: Chiropractic

Justification CK: Consent

Form(s) CT: Certification D2: Drug Profile

Document DA: Dental

Models DB: Durable

Medical Equipment Prescription

DG: Diagnostic Report

DJ: Discharge Monitoring Report

DS: Discharge Summary

EB: Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payor)

HC: Health

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

Benefits or Medicare Secondary Payor)

MT: Models NN: Nursing

Notes OB: Operative

Note OZ: Support

Data for Claim

Certificate HR: Health Clinic

Records I5: Immunization

Record IR: State School

Immunization Records

LA: Laboratory Results

M1: Medical Record Attachment

MT: Models NN: Nursing

Notes OB: Operative

Note OC: Oxygen

Content Averaging Report

OD: Orders and Treatments Document

OE: Objective Physical Examination (including vital signs) Document

OX: Oxygen Therapy Certification

OZ: Support Data for Claim

P4: Pathology Report

P5: Patient Medical History Document

PE: Parental or Enteral Certification

PN: Physical Therapy Notes

PO: Prosthetics

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

PN: Physical

Therapy Notes

PO: Prosthetics or Orthotic Certification

PZ: Physical

Therapy Certification

RB: Radiology Films

RR: Radiology Reports

RT: Report of Tests and Analysis Report

or Orthotic Certification

PQ: Paramedical Results

PY: Physician’s Report

PZ: Physical Therapy Certification

RB: Radiology

Films RR: Radiology

Reports RT: Report of

Tests and Analysis Report

RX: Renewable Oxygen Content Averaging Report

SG: Symptoms Document

V5: Death Notification

XP: Photographs

2300 PWK02 Claim Supplemental Information Attachment Transmission Code

AA: Available on Request at Provider Site

BM: By Mail EL:

Electronically Only

EM: E-Mail FX: By Fax

AA: Available on Request at Provider Site

BM: By Mail EL: Electronically

Only EM: E-Mail FT: File Transfer FX: By Fax

Code Added

2300 PWK07 Claim Supplemental Information Description

Element Deleted

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 CN101 Contract Information Contract Type Code

02: Per Diem 03: Variable

Per Diem 04: Flat 05: Capitated 06: Percent 09: Other

01: Diagnosis Related Group (DRG)

02: Per Diem 03: Variable Per

Diem 04: Flat 05: Capitated 06: Percent 09: Other

Code Added

2300 CN104 Contract Information Contract Code


2300 AMT Payer Estimated Amount Due Segment

Deleted

2300 AMT01 Payer Estimated Amount Due Amount Qualifier Code

Element Deleted MA: Maximum

Amount

2300 AMT02 Payer Estimated Amount Due Element Deleted

2300 AMT Patient Amount Paid Segment

Deleted

2300 AMT01 Patient Amount Paid Amount Qualifier Code


Amount

2300 AMT02 Patient Amount Paid Element Deleted

2300 AMT Credit/Debit Card Maximum Amount

Segment Deleted

2300 AMT01

Credit/Debit Card Maximum Amount Amount Qualifier Code


Amount

2300 AMT02 Credit/Debit Card Maximum Amount

Element Deleted

2300 REF02

Service Authorization Exception Code Reference Identification

Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘4N’) Maximum length increase from 30 – 50

2300 REF02 Referral Number Reference Identification

Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘9F’) Maximum length increase from 30 – 50

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 REF02 Prior Authorization Number Reference Identification

Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘G1’) Maximum length increase from 30 – 50

2300 REF02

Original Reference Number (ICN/DCN) Reference Identification


(REF01 qualifier value ‘F8’) Renamed from 4010A1 – ‘Original Reference Number (ICN/DCN)’ Maximum length increase from 30 – 50

2300 REF02 Repriced Claim Number Reference Identification

Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘9A’) Maximum length increase from 30 – 50

2300 REF02 Adjusted Repriced Claim Number Reference Identification

Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘9C’) Maximum length increase from 30 – 50

2300 REF Investigational Device Exemption Number

Max Occurrence: 1

Max Occurrence: 5 Change in maximum segment repeat

2300 REF02

Investigational Device Exemption Number Reference Identification

Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘LX’) Maximum length increase from 30 – 50

2300 REF02

Claim Identifier for Transmission Intermediaries Reference Identification


(REF01 qualifier value ‘D9’) Renamed from 4010A1 – ‘Claim Identification Number for Clearinghouses and Other Transmission Intermediaries’’ Maximum length increase from 30 – 50

2300 REF Document Identification Code Segment

Deleted

2300 REF01 Document Identification Code Reference Identification Qualifier

Element Deleted DD: Document

Identification Code

2300 REF02 Document Identification Code Reference Identification

Element Deleted

2300 REF Auto Accident State New Segment


Situational Rule: Required when the services

reported on this claim are related to an auto accident

and the accident occurred in a country or location

that has a state, province, or sub-country code

named in code source 22. If not required by this


of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 REF01 Auto Accident State Reference Identification Qualifier

New Element LU: Location

Number

Usage: Required when segment is present

2300 REF02 Auto Accident State Reference Identification


Usage: Required when segment is present

2300 REF02 Medical Record Number Reference Identification

Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘EA’ Maximum length increase from 30 – 50

2300 REF02 Demonstration Project Identifier Reference Identification

Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘P4 Maximum length increase from 30 – 50

2300 REF02 Peer Review Organization (PRO) Approval Number Reference Identification

Length: 1 - 30 Length: 1 - 50 (REF01 qualifier value ‘P4) Maximum length increase from 30 – 50

2300 CR6 Home Health Care Information Segment

Deleted

2300 CR601 Home Health Care Information Prognosis Indicator

Element Deleted

2300 CR602 Home Health Care Information Service From Date

Element Deleted

2300 CR603 Home Health Care Information Date Time Period Format Qualifier

Element Deleted


Element Deleted

2300 CR605 Home Health Care Information Diagnosis Date

Element Deleted

2300 CR606 Home Health Care Information Skilled Nursing Facility Indicator

Element Deleted

2300 CR607 Home Health Care Information Medicare Coverage Indicator

Element Deleted

2300 CR608 Home Health Care Information Certification Type Indicator

Element Deleted

2300 CR609 Home Health Care Information Surgery Date

Element Deleted

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 CR610 Home Health Care Information Product or Service ID Qualifier

Element Deleted

2300 CR611 Home Health Care Information Surgical Procedure Code

Element Deleted

2300 CR612 Home Health Care Information Physician Order Date

Element Deleted

2300 CR613 Home Health Care Information Last Visit Date

Element Deleted

2300 CR614 Home Health Care Information Physician Contact Date

Element Deleted


Element Deleted

2300 CR616 Home Health Care Information Last Admission Period

Element Deleted

2300 CR617

Home Health Care Information Patient Discharge Facility Type Code

Element Deleted


Element Deleted


Element Deleted


Element Deleted


Element Deleted

2300 CRC Home Health Functional Limitations

Segment Deleted

2300 CRC01

Home Health Functional Limitations Code Category

Element Deleted

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 CRC02

Home Health Functional Limitations Certification Condition Indicator

Element Deleted

2300 CRC03

Home Health Functional Limitations Functional Limitations Code

Element Deleted

2300 CRC04


Element Deleted

2300 CRC05


Element Deleted

2300 CRC06


Element Deleted

2300 CRC07


Element Deleted

2300 CRC Home Health Activities Permitted Segment

Deleted

2300 CRC01 Home Health Activities Permitted Code Category

Element Deleted

2300 CRC02 Home Health Activities Permitted Certification Condition Indicator

Element Deleted

2300 CRC03 Home Health Activities Permitted Activities Permitted Code

Element Deleted


Element Deleted


Element Deleted


Element Deleted

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes


Element Deleted

2300 CRC Home Health Mental Status Segment

Deleted

2300 CRC01 Home Health Mental Status Certification Condition Indicator

Element Deleted

2300 CRC02 Home Health Mental Status Certification Condition Indicator

Element Deleted

2300 CRC03 Home Health Mental Status Mental Status Code

Element Deleted


Element Deleted

2300 CRC05 Home Health Mental Status Activities Permitted Code

Element Deleted


Element Deleted


Element Deleted

2300 CRC EPSDT Referral New Segment


Situational Rule: Required on Early & Periodic

Screening, Diagnosis, and Treatment (EPSDT) claims

when the screening service is being billed in this

claim. If not required by this implementation guide,

do not send.

2300 CRC01 EPSDT Referral Code Category

New Element ZZ: Mutually

Defined EPSDT

Screening referral information

Usage: Required

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 CRC02 EPSDT Referral Certification Condition Indicator

New Element N: No Y: Yes

Usage: Required

2300 CRC03 EPSDT Referral Condition Code

New Element AV: Available -

Not Used NU: Not Used S2: Under

Treatment ST: New

Services Requested

Usage: Required




Treatment ST: New

Services Requested

Usage: Situational




Treatment ST: New

Services Requested

Usage: Situational

2300 HI

The implementation of the HI segment for diagnosis

codes has been significantly changed between the

4010 and 5010 standards.

The 4010A1 standard carried Principal, Admitting, E

Code, and Patient Reason For Visit Diagnosis

Information on a single HI segment.

In the 5010 standard, each of these diagnosis codes

is carried on a separate instance of the HI segment.

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 HI Principal Diagnosis

Usage: Required This instance of the HI segment carries only principal diagnosis code

2300 HI01

Principal Diagnosis Healthcare Diagnosis Code Information

2300 HI01-01 Principal Diagnosis Code List Qualifier

ABK: International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

BK: International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

Usage: Required

2300 HI01-02 Principal Diagnosis Principal Diagnosis Code

Diagnosis Code Usage: Required

2300 HI01-09 Principal Diagnosis Present on Admission Indicator

New Element N: No U: Unknown W: Not

applicable Y: Yes


SITUATIONAL RULE: Required as directed by the NUBC

billing manual.

2300 HI Admitting Diagnosis

Usage: Situational This instance of the HI segment carries only the admitting diagnosis code TR3 Usage Rule:

Situational Rule: Required when claim involves an

inpatient admission. If not required by this


of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 HI01

Admitting Diagnosis Healthcare Diagnosis Code Information

2300 HI01-01 Admitting Diagnosis Code List Qualifier

ABJ: International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

BJ: International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

Usage: Required

2300 HI01-02 Admitting Diagnosis Diagnosis Code


2300 HI Patient Reason for Visit

Usage: Situational This instance of the HI segment carries only the patient reason for visit diagnosis codes. TR3 Usage Rule:

Situational Rule: Required when claim involves

outpatient visits. If not required by this


2300 HI01

Patient’s Reason for Visit Healthcare Diagnosis Code Information

Usage: Required

of 137

Loop Segment /


4010

Valid Values

and

Descriptions

5010

Valid Values

and

Descriptions

5010A2

Valid Values

and

Descriptions

Notes

2300 HI01-01 Patient’s Reason for Visit Code List Qualifier

APR: International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

PR: International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

Usage: Required

2300 HI01-02 Patient’s Reason for Visit Diagnosis Code


2300 HI02 HI03

Patient’s Reason for Visit Healthcare Diagnosis Code Information


SITUATIONAL RULE: Required when an additional

Date post:	01-Feb-2021
Category:	Documents
Upload:	others
View:	1 times
Download:	0 times

837 I 5010A2 Conversion Business Impacts...subscriber or is considered to be the subscriber and is...

Documents