Cardinal Innovations Companion Guide
Health Care Claim: Institutional (837I) ASC X12 005010X223A2
March 2018 ● 005010 1
Cardinal Innovations Healthcare
837I Companion Guide
Instructions Related to Transactions Based on ASC X12 Implementation Guide
Version 005010X223A2 Health Care Claim: 837 Institutional
Companion Guide Version Number: 3.1 March 28, 2018
Cardinal Innovations Companion Guide
Health Care Claim: Institutional (837I) ASC X12 005010X223A2
March 2018 ● 005010 2
This template is copyrighted © 2010 by The Workgroup for Electronic Data Interchange (WEDI) and the Data Interchange Standards Association (DISA), on behalf of the Accredited Standards Committee (ASC) X12. All rights reserved. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided “as is” without any express or implied warranty. Note that the copyright on the underlying ASC X12 Standards is held by DISA on behalf of ASC X12. 2018 © Companion Guide copyrighted by Cardinal Innovations
Cardinal Innovations Companion Guide
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Preface Companion Guides (CG) may contain two types of data, instructions for electronic
communications with the publishing entity (Communications/Connectivity Instructions) and
supplemental information for creating transactions for the publishing entity while ensuring
compliance with the associated ASC X12 IG (Transaction Instructions). Either the
Communications/Connectivity component or the Transaction Instruction component must be
included in every CG. The components may be published as separate documents or as a single
document.
The Communications/Connectivity component is included in the CG when the publishing entity
wants to convey the information needed to commence and maintain communication exchange.
The Transaction Instruction component is included in the CG when the publishing entity wants
to clarify the IG instructions for submission of specific electronic transactions. The Transaction
Instruction component content is limited by ASCX12’s copyrights and Fair Use statement.
Cardinal Innovations Companion Guide
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Table of Contents
1 TI Introduction .......................................................................................................... 5
1.1 Background ................................................................................................................... 5
1.1.1 Overview of HIPAA Legislation ........................................................................... 5
1.1.2 Compliance according to HIPAA ......................................................................... 5
1.1.3 Compliance according to ASC X12 ..................................................................... 6
1.2 Intended Use ................................................................................................................. 6
1.3 Intended Audience ........................................................................................................ 6
1.4 Purpose of Companion Guide ....................................................................................... 6
1.5 Trading Partner Agreement ........................................................................................... 6
1.6 Resources ..................................................................................................................... 6
1.7 Version Updates............................................................................................................ 6
2 Included ASC X12 Implementation Guides ............................................................ 7
3 Instruction Tables .................................................................................................... 8
4 TI Change Summary .............................................................................................. 15
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Transaction Instruction (TI)
1 TI Introduction
1.1 Background
1.1.1 Overview of HIPAA Legislation
The Health Insurance Portability and Accountability Act (HIPAA) of 1996
carries provisions for administrative simplification. This requires the
Secretary of the Department of Health and Human Services (HHS) to adopt
standards to support the electronic exchange of administrative and financial
health care transactions primarily between health care providers and plans.
HIPAA directs the Secretary to adopt standards for transactions to enable
health information to be exchanged electronically and to adopt specifications
for implementing each standard HIPAA serves to:
Create better access to health insurance
Limit fraud and abuse
Reduce administrative costs
1.1.2 Compliance according to HIPAA
The HIPAA regulations at 45 CFR 162.915 require that covered entities not
enter into a trading partner agreement that would do any of the following:
Change the definition, data condition, or use of a data element or segment in a
standard.
Add any data elements or segments to the maximum defined data set.
Use any code or data elements that are marked “not used” in the standard’s
implementation specifications or are not in the standard’s implementation
specification(s).
Change the meaning or intent of the standard’s implementation specification(s).
1.1.3 Compliance according to ASC X12
ASC X12 requirements include specific restrictions that prohibit trading
partners from:
Modifying any defining, explanatory, or clarifying content contained in the
implementation guide.
Modifying any requirement contained in the implementation guide.
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1.2 Intended Use
The Transaction Instruction component of this companion guide must be used in
conjunction with an associated ASC X12 Implementation Guide. The instructions
in this companion guide are not intended to be stand-alone requirements
documents. This companion guide conforms to all the requirements of any
associated ASC X12 Implementation Guides and is in conformance with ASC
X12’s Fair Use and Copyright statements.
1.3 Intended Audience
This companion guide is intended for business and technical users responsible for
the testing and setup of electronic claims submissions between Trading Partners
and Cardinal Innovations Network.
1.4 Purpose of Companion Guide
The Companion Guide is to be used with, and to supplement, the requirements in
the HIPAA ASC X12 Implementation Guides, without contradicting those
requirements. The HIPAA ASC X12 Implementation Guides Implementation
Guides define the national data standards, electronic format, and values for each
data element within an electronic transaction. The purpose of the Companion
guide is to provide Trading Partners with a guide to communicate specific Cardinal
Innovations Network information required to successfully exchange transactions.
1.5 Trading Partner Agreement
Providers or vendors who directly transmit electronic claims to Cardinal
Innovations must complete a Cardinal Innovations Trading Partner Agreement
(TPA).
1.6 Resources
The following resources were used in preparing this Companion Guide.
Washington Publishing Company www.wpc-edi.com
ASC X12 www.X12.org
NCTracks www.nctracks.nc.gov
1.7 Version Updates
This Companion Guide will be updated as needed based on changes to Federal
guidelines and Cardinal Innovation Healthcare’s claim adjudication requirements.
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Included ASC X12 Implementation Guides
This table lists the X12N Implementation Guides for which specific transaction
Instructions apply and which are included in Section 3 of this document.
Unique ID Name 005010X223 Health Care Claim: Professional (837I) 005010X223A1 Health Care Claim: Professional (837I) 005010X223A2 Health Care Claim: Professional (837I)
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2 Instruction Tables
These tables contain one or more rows for each segment for which a supplemental
instruction is needed.
Legend
SHADED rows represent “loops and segments” in the X12N implementation guide.
NON-SHADED rows represent “data elements” in the X12N implementation guide.
005010X222A1 Health Care Claim: Professional
Loop ID Reference Name Codes Notes/Comments
Header ISA Interchange
Control Header
ISA03 Interchange Control Security Information
Qualifier
00 Use “00” – No Security Information
Present.
ISA05 Interchange ID
(Sender) Qualifier ZZ Use “ZZ” – Mutually
Defined.
ISA06 Interchange
Sender ID
Use the Submitter ID issued to you by Cardinal Innovations. Same as
GS02.
ISA07 Interchange ID
(Receiver) ID
ZZ Use “ZZ” – Mutually
Defined.
ISA08 Interchange
Receiver ID
Use “06607”. Same as GS03.
Header GS Functional Group
Header
GS02 Application
Sender’s Code Use the Submitter ID
issued to you by Cardinal
Innovations. Same as
ISA06.
GS03 Application
Receiver’s Code Use “06607”. Same as
ISA08.
Header ST Transaction Set Header
ST03 Implementation Conversion Reference
005010X223
A2
Refer to section 1.2 of
Implementation Guide
1000A NM1 Submitter Name
NM108 Identification Code Qualifier
46 Use “46” - Electronic Transmitter ID Number
NM109 Identification Use the Submitter ID
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Loop ID Reference Name Codes Notes/Comments
Code issued to you by Cardinal Innovations. Same as ISA
ISA06 and GS02.
1000B NM1 Receiver Name
NM103 Receiver Name Use “Cardinal Innovations”
NM108 Identification Code Qualifier
46 Use “46” - Electronic Transmitter ID Number
NM109 Receiver Primary Identifier
Use “06607”. Same as ISA ISA08 and GS03.
2000A Billing Provider Hierarchy Level
The Billing Provider Information is critical to successfully adjudicating a
provider claim. The Billing Provider’s NPI number, taxonomy code and nine-digit zip code must be enrolled at NCTracks in a current and active provider record with a service
location code of ‘03’ or greater. Billing Provider entries must also follow the NPI enumeration rules detailed
in the X12 837I TR3 (Federal implementation guide). If a Provider site
has its own unique NPI number, then that site must be listed as the Billing Provider in the
837I.
2000A PRV Billing Provider Specialty
Required by Cardinal Innovations. Enter the taxonomy code in the Billing Provider Loop.
PRV01 Provider Code BI Use “BI” – Billing Provider
PRV02 Identification Code Qualifier
PXC Use “PXC” – Taxonomy Code
PRV03 Taxonomy Code Use the Billing Provider’s
Taxonomy Code. This
taxonomy code must be listed in an active NCTracks provider record that also contains the NPI used in 2010AA, NM109 and the nine digit zip code used in Loop 2010AA,
N403.
2010AA NM1 Billing Provider Name
NM108 Billing Provider ID XX Use “XX” = NPI number
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Loop ID Reference Name Codes Notes/Comments
Qualifier
NM109 Billing Provider ID Use the Billing Provider’s NPI number. This NPI number must be listed in an active NCTracks provider record that also contains the Taxonomy code used in 2000A,
PRV03 and the nine digit zip code used in Loop 2010AA, N403.
2010AA NM4 Billing Provider City, State, Zip Code
N403 Billing Provider Nine-Digit Zip Code
Use the Billing Provider’s nine-digit zip code. This nine-digit zip code must be listed in an active NCTracks provider record that also contains the NPI
used in 2010AA, NM109 and the Taxonomy code used in 2000A, PRV03.
2010AC Pay-to-Plan Cardinal Innovations will
not use this loop
2000B SBR Subscriber Information
SBR09 Claim Filing
Indicator Code MC, ZZ Use “MC” for Medicaid
claims Use “ZZ” – State Funds
claims
2010BA NM1 Subscriber Name
NM108 Identification Code Qualifier
MI Use “MI” - Member Identification Number
NM109 Subscriber Primary Identifier
For Medicaid, use the Member’s 10 digit Medicaid ID ending in an alpha character. For State Funds, use the Member’s ID number
assigned by the MCO.
2010BB NM1 Payer Name
NM103 Payer Name Use “Cardinal Innovations”
NM108 Payer ID Qualifier PI Use “PI” – Payer ID
NM109 Payer Identifier Use “06607”. Same as ISA
ISA08 and GS03.
2300 CLM Claim Information
CLM05-3 Claim Frequency Code 1,2,3,4,7,8 It is very important to use the correct frequency code, patient status code,
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Loop ID Reference Name Codes Notes/Comments
covered days and statement span in order to
determine whether the last day of the episode is billable. These fields must be in sync. 1 = Full episode claim, discharged 2 = First claim, not
discharged 3 = Interim claim, not discharged 4 = Discharge claim 7 = Replacement claim
8 = Void claim
2300 DTP Discharge Time
DTP01 Discharge Time Code O96 096 = Discharge Date
DTP02 Date Time Qualifier TM TM = Time
DTP03 Discharge Time HHMM format
2300 DTP Statement Date Range
DTP01 Statement Date Code 434 434 = Statement Date
DTP02 Date Time Qualifier RD8 RD8 = Date Range
DTP03 Statement Date Range CCYYMMDD - CCYYMMDD
2300 DTP Admission Date
DTP01 Admission Date Code 435 435 = Admission Date
DTP02 Date Time Qualifier D8, DT D8 = CCYYMMDD
DT = CCYYMMDDHHMM
DTP03 Admission Date Time CCYYMMDD format or CCYYMMDDHHMM
Note: The discharge time,
statement dates and admission date must be in sync with the claim frequency code, the patient status code and the covered days.
2300 CL1 Institutional Claim Codes
CL103 Patient Status Code Must use
codes from
the NUBC
code list
The patient status code must clearly indicate whether the patient has
been discharged or is still a patient. The code must be in sync with the claim frequency code, the statement dates and the covered days.
2300 REF Payer Claim Control Number
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Loop ID Reference Name Codes Notes/Comments
REF01 Reference Identification Qualifier
F8 Use “F8” - Original Reference Number - when
CLM05-3 is equal to 7 or 8
REF02 Reference Identification
Use Cardinal Innovation’s ICN associated with the original claim that is being replaced or voided
2300 HI Value Code – Patient Monthly Liability
HI01 Health Care Code Information
Use to report Patient Monthly Liability (PML) contributions for ICF/IDD
patients.
HI01-1 Qualifier Code BE Use “BE” - Value
HI01-2 Value Code 23 Use “23” – Patient Share of Cost
HI01-5 Value Amount Dollar amount of PML
contribution. This should only be reported on the first claim of the month or until the SSI is depleted for the month.
2300 HI Condition Code – Covered Days
HI01 Health Care Code Information
Use to report the number of covered days for an inpatient stay.
HI01-1 Qualifier Code BE Use “BE” - Value
HI01-2 Value Code 80 Use “80” – Covered Days
HI01-5 Value Amount The number of inpatient days for which the provider expects Cardinal
Innovations Healthcare to pay. The covered days must be in sync with the claim frequency code, the statement dates and the patient status code.
2310E Service Facility Location Information
The Service Facility Location is the site where
the service was delivered. Required by Cardinal Innovations if the Service
Facility Location Information is different than the Billing Provider Information in Loop 2010AA. Service Facility Location
entries must also follow
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Loop ID Reference Name Codes Notes/Comments
the NPI enumeration rules detailed in the X12 837I
TR3 (Federal implementation guide). If a Provider Site/Service Facility Location has its own unique NPI number, then that Site/Service Facility Location must be
listed as the Billing Provider in the 837I. The NPI information in Loop 2310E is situational,
meaning that the service might have been delivered
at a site that does not have an NPI number. Also, the site might be a Billing Provider site that was not enumerated, meaning that the site does not have a
unique NPI. In these cases, the 2310E, NM108 and NM109 will not be used. The address and nine-digit zip code are still required.
2310E NM1 Service Facility
Location Name
NM108 Service Facility Location ID Qualifier
XX 2310E NM108 is a situational field. Use “XX” = NPI number, if the
Service Facility Location has an NPI number.
NM109 Service Facility Location ID
2310E NM109 is a situational field. Use the Service Facility Location’s NPI number if the Service
Facility Location has a unique NPI number. This NPI number must be listed in an active NCTracks provider record
that also contain the nine-digit zip code used in Loop
2310E N403.
2310E N4 Service Facility Location City, State, Zip
N403 Service Facility Location Nine-Digit Zip Code
If the Service Facility Location NPI field is used, then the Service Facility Location nine-digit zip code and NPI must be
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Loop ID Reference Name Codes Notes/Comments
listed in an active NCTracks provider record.
If the Service Facility Location NPI is not used, then the nine-digit Service Facility Location zip code must be linked to the Billing Provider NPI and
Taxonomy code in Loop 2010AA.
2320 Other Subscriber Information
2320 AMT Coordination of
Benefits Other Payer Paid Amount
AMT01 Amount Qualifier Code D Cardinal Innovations only uses “D” – Payer Amount Paid
AMT02 Other Payer Paid Amount
2410 LIN Drug identification Loop 2410 is required when a drug is administered by a provider during an emergency room
visit and a drug related HCPCS code is reported in SV202-2. Cardinal Innovations only pays for
drugs for Medicaid Members administered during an emergency room
visit, or administered during Hospital Outpatient procedures. Prescriptions and self-administered drugs are not covered.
2410 REF Prescription or
Compound Drug Association Number
REF01 Reference Identification Qualifier
VY Use “VY” - Link Sequence Number
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3 TI Change Summary Version 1.0 January 1, 2014 Cardinal Innovations
Version 2.0 February 1, 2018 Cardinal Innovations
Version 3.0 March 21, 2018 Cardinal Innovations
Version 3.1 March 28, 2018 Cardinal Innovations